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Section 25
Depression in the Adult Children of Alcoholics

Question 25 | Test | Table of Contents

In the last two decades, the knowledge base about the physical and psychological concerns experienced by adult children of alcoholics (ACOAs) has expanded rapidly. Much of the early literature was clinically based and anecdotal in nature. More recently, researchers have begun to question the assumption that all ACOAs are homogeneous in terms of their familial experiences and the psychological effects that may result from these experiences. It is likely that alcoholic families can be characterized on a continuum of dysfunction and that there are numerous within-group differences in their environments and experiences.

Parental drinking style is another factor that has been mentioned in the clinical literature as a variable that might account for some of the within-group differences for ACOAs (J. L. Johnson & Roll, 1990). Not all alcoholics exhibit the same affect or behavior during the drinking period. Violent and abusive behavior may be exhibited during drinking. Alternatively, the drinking parent may emotionally or physically withdraw and thus be unavailable to the family. Another often-cited problematic area for ACOAs is that of interpersonal relationships (Black, 1981; Woititz, 1985). Yet, with the more recent focus on within-group differences, one should not expect all ACOAs to experience difficulties in this realm either. One concept related to interpersonal relationships that has received recent attention is that of attachment theory. Attachment theory grew out of infant development literature and is based on the premise that the infant’s ability to develop a secure emotional bond with the caregiver provides the security necessary for environmental exploration (Ainsworth, Blehar, Waters, & Wall, 1978; Bowlby, 1982) and forms the foundation for the development of later interpersonal relationships. Emotional availability and responsiveness of caregivers are crucial to the formation of a working model of self as worthy of care and of attachment figures as caring and responsive to needs.

Recently the concept of attachment has been applied to adult patterns of attachment (Feeney & Noller, 1990; Hazan & Shaver, 1987; Kirkpatrick & Hazan, 1994; Simpson, 1990), where attachment is seen as emotional bonding to a partner who is a source both of security and of comfort (Bowlby, 1988). A positive view of self and others is associated with secure attachment, whereas a negative view of self and others is associated with fearful attachment. Secure attachment behaviors have been associated with more positive and stable romantic relationships (Feeney & Noller, 1990; Pistole, 1989; Simpson, 1990). Negative self-view and positive other-view is related to preoccupied attachment, whereas positive self-view and negative other-view is related to a dismissing style. Persons with a preoccupied attachment are hypervigilant to separation from their partners (Mikulincer, Florian, & Tolmacz, 1990) and display high levels of emotional dependence on their partners (Bartholomew & Horowitz, 1991), whereas the dismissing style has been associated with emotional distance (Hazan & Shaver, 1987), perhaps as a defensive mechanism.

Just as difficulties with attachment have been linked to adult psychological distress, so too have early familial experiences been related to later attachment styles. Lopez (1995) found that secure and preoccupied students reported higher levels of parental warmth and affection relative to their dismissive and fearful peers, and secure study participants experienced less maternal control and intrusiveness than did those who were insecurely attached. Cohn (1993) reported that female ACOAs had a dysfunctional attachment profile. Mothersead, Kivlighan, and Wynkoop (1998) found that parental alcoholism had no direct effect on attachment or interpersonal distress but that parental attachment mediated the relationship between family dysfunction and difficulties with intimacy and overcontrol. Brennan, Shaver, and Tobey (1991) noted that ACOAs tended to experience a higher proportion of insecure attachment styles (fearful and avoidant) than seen in the general population, whereas Clark, Shaver, and Calverley (1994) reported that women who had a fearful attachment style also reported a history of abuse and of witnessing parental violence. Physical and psychological abuse often accompany alcohol abuse, and it may be these more blatantly disruptive styles of behavior during alcohol consumption that lead to difficulties in forming healthy family relationships and later intimate attachments.

The research question in this study examines whether or not levels of depression experienced by a college population consisting of both ACOAs and non-ACOAs are related to the patterns of parental drinking behaviors to which they had been exposed, intergenerational family interactions, current attachment behaviors with intimate partners, and consequent self-esteem.

Direct Effects 
Depression and self-esteem. With depression as the criterion variable, the direct effects of the variables on depression hypothesized by the model are partially supported. Neither behavioral pattern of drinking had a direct influence on depression. Intergenerational intimacy and personal authority were the only two significant family variables in the model that influenced the outcome. Intergenerational intimacy had a positive effect indicating that when the effects of all other variables were controlled for, depression increased as intimacy increased; depression also increased as personal authority decreased. Self-esteem had a direct influence on depression such that lower levels of self-esteem were associated with higher levels of depression. Attachment styles had no direct influence on depression. With self-esteem as the criterion variable, intergenerational intimacy and triangulation influenced self-esteem, as did the fearful attachment style, such that increased triangulation, decreased intimacy, and a more fearful style were related to decreased self-esteem. The other family process variables, drinking styles, and the secure attachment style did not significantly predict self-esteem.

Attachment styles. No family variable or drinking style had an effect on secure attachment, although personal authority approached significance. Two variables showed direct effects for the fearful attachment: age and intergenerational intimacy. Decreased intimacy was related to a more fearful attachment style, as was a younger age. The angry/violent drinking style had an effect size which did not achieve statistical significance but could be considered a significant effect. This tentative finding suggested that an angry/violent drinking style was related to a fearful attachment style.

Intergenerational family process variables. As hypothesized, age did have an effect on the family variables, but only on intergenerational intimidation, while the angry/violent drinking style influenced intergenerational intimacy, intergenerational intimidation, and personal authority and approached significance in influencing intergenerational triangulation. The angry/violent drinking style was associated with decreased intimacy and personal authority as well as with increased intimidation. The quiet, but visibly present drinking style influenced intergenerational intimidation; higher scores on the measure of quiet drinking were associated with less intimidation.

Indirect Effects
The fearful attachment style had an indirect influence on depression through the mediating effect of self-esteem. Family process variables of intergenerational triangulation and intergenerational intimacy also influenced depression through the mediation of self-esteem. The pattern of angry drinking behavior by a male parent approached, but did not achieve, a statistically significant indirect effect. The angry/violent style did have a significant indirect influence on self-esteem and fearful attachment; both were mediated by intergenerational intimacy.

Discussion
This study tested a model predicting that parental drinking behaviors would be associated with depression but that this relationship would be mediated by disrupted multigenerational family processes, insecure attachment, and lower levels of self-esteem. Results partially supported the hypothesized model. The drinking patterns exhibited by the male parent had no direct effect on depression but did directly affect multigenerational family functioning and indirectly influenced self-esteem. However, it was primarily a drinking pattern characterized by loud, violent, or abusive behavior that was influential. The visibly present but quiet drinking pattern had minimal effect in the model. This suggests that it is necessary to look beyond the simple categorization of ACOA to the type of alcoholic behaviors displayed in the household. In addition, muitigenerational family interactions were affected by drinking behaviors and then influenced self-esteem and depression. These family interactions also had an indirect influence on depression through the mediating influence of self-esteem. Thus, it is important to attend to the familial interaction patterns that occur within the alcoholic family and how those patterns may disrupt healthy attachments and decrease self-esteem, which then predisposes one to be vulnerable to depression.

Consistent with other findings relating attachment styles to marital adjustment (Lussier, Sabourin, & Wright, 1994), the experience of abuse (Clark et al., 1994), depressive attributional styles (Kennedy, 1996), and to psychological symptoms including depression (Lussier, Sabourin, & Lambert, 1994), the fearful attachment style indirectly influenced depression through the mediation of self-esteem. These data are consistent with findings that early negative experiences, such as inadequate parenting, contribute to negative cognitive styles and that cognitive vulnerability to depression (i.e., dysfunctional attitudes about self and low self­esteem) may be influenced by insecurity in adult attachments (Roberts et al., 1996). Such insecurity is thought to be the result of negative transactions with significant others over time. The present study suggests that those negative transactions are influenced by angry and violent parental drinking behaviors but not by less disruptive drinking behaviors.

These findings regarding the direct and indirect effects that drinking patterns, intergenerational family processes, attachment behaviors, and self-esteem have on depression support recent observations about the heterogeneity of the ACOA group and suggest that some of their frequently cited concerns are not the result of the alcoholism, per se, but of the family disruption that occurs when the angry and violent drinking behaviors begin a chain reaction of dysfunctional family processes, insecure attachments, and decreased self-esteem.  These differences must be considered when working with this population so that assumptions about the presence of pathology (e.g., depression, decreased self-esteem, relationship difficulties) are not made exclusively on the basis of ACOA classification. Given the link between the fearful attachment style and the witnessing and receipt of abuse (Clark et al., 1994; Smith-Heinzl, Henderson, & Bartholomew, 1994) and contact with an angry or violent style of drinking in the present study, it may be that Brennan et al’s (1991) finding that ACOAs tend to experience a higher proportion of insecure attachment styles applies more specifically to ACOAs exposed to angry and violent drinking environments. It certainly is plausible that an angry drinking style could be seen as physically, as well as psychologically, abusive of family members, and it could be this abuse and the resultant disruption of healthy family functioning and later adult attachment styles that partially predict the distress an individual experiences.

The findings relating current levels of depression to early family experiences with intimacy and disrupted attachment have important counseling implications. Disrupted attachment may result in consequent working models of self and others that predispose one to depression. Treatment may focus on mourning childhood losses, developing intimacy, and achieving healthy individuation rather than the more general identification of familial alcoholism. In a similar vein, current attachment literature conceptualizes the construct of attachment as relatively stable but conducive to modification in the context of a secure relationship (Hazan & Shaver, 1994). Bowlby (1988) suggested that the therapeutic environment could provide a corrective attachment experience through the counselor’s role as a consistently responsive attachment figure who disconfirms insecure expectations of unreliability or rejection. If fearful attachment is the influential variable on depression that it seems to be, then providing a corrective experience through the therapeutic alliance could result in increased self-esteem, which in turn could decrease levels of depression.

Personal Reflection Exercise #11
The preceding section contained information about depression in the adult children of alcoholics.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Mortality in adult children of parents with alcohol use
disorder: a nationwide register study

- Westman, J., Jayaram-Lindström, N., Kane, K., Franck, J., & Gissler, M. (2022). Mortality in adult children of parents with alcohol use disorder: a nationwide register study. European journal of epidemiology, 37(8), 815–826. https://doi.org/10.1007/s10654-022-00883-4

Peer-Reviewed Journal Article References:
Acheson, A., Vincent, A. S., Cohoon, A., & Lovallo, W. R. (2019). Early life adversity and increased delay discounting: Findings from the Family Health Patterns project. Experimental and Clinical Psychopharmacology, 27(2), 153–159.

Joyner, K. J., Acuff, S. F., Meshesha, L. Z., Patrick, C. J., & Murphy, J. G. (2018). Alcohol family history moderates the association between evening substance-free reinforcement and alcohol problems. Experimental and Clinical Psychopharmacology, 26(6), 560–569.

Roy, A. L., Isaia, A., & Li-Grining, C. P. (2019). Making meaning from money: Subjective social status and young children’s behavior problems. Journal of Family Psychology, 33(2), 240–245.

QUESTION 25
According to Lease, the angry/violent drinking behavior style had what influences on the adult children of alcoholics? Record the letter of the correct answer the Test.