Feelings and codependent behavior in the family of illicit drugs users

Current descriptive and qualitative study described feelings and codependent behavior in relatives of illicit drug users. Data were collected between March and April 2012 by an open interview with eight family members of illicit drugs-dependent individuals and subjected to theme-mode content analysis. Results were classified into two categories which showed intense suffering coupled to feelings of guilt, fear, shame, sadness, shame and manifestation of codependent behaviors such as denial and control of the one ́s situation and that of others. Professionals should know the situation in which the families of drug addicts live to assist them in a different way. They should also identify codependent relatives, since they also need care so that their behavior does not worsen the symptoms and behavior of the drug user and prevents a possible medical or psychiatric diagnosis.


Introduction
The use of illicit drugs endangers the health and well-being of people worldwide, impairing the social and economic development of nations.Approximately 167 -315 million people between 14 and 64 years old, or rather, 3.6 -6.9% of the entire adult population, have already used illicit chemical substances (United Nations Office on Drugs and Crime, 2013).
Such global impairment demonstrates that addressing the issue of psychoactive drugs should go beyond the drug user´s individual level since their use affects the personal, social and familial context, with damaging consequences.Interventions for the prevention, treatment and rehabilitation should include actions directed at these different contexts (Souza, Kantorski, Vasters, & Luis 2011).
The illicit use of drugs practically leads towards chemical dependency.In its turn, chemical dependency actually causes intense organic and psychic suffering to the individuals concerned and their families.The use of drugs by a single family member impacts the family as a whole, causing a rupture in the family structure due to a feeling that it has not coped adequately with change through its dynamics and functioning.
Various arrangements may be adopted by the family when it experiences a critical condition.In fact, some are better able to cope with the situation, and quickly adapt themselves to the changes, whereas others have great difficulty in facing the issue and may even display inappropriate behavior, characterized as codependent behavior (Zampieri, 2004).
The concept of codependency originally described certain types of behavior manifested by relatives and friends of people addicted to alcohol (Biscarra, 2010).It was later conceived within a broader contextualized situation, by which, as a rule, the family systematically favors the maintenance of dependency in others.This occurs when they prevent them from responding to and being accountable for their actions and for the consequences caused by drug use, since this discourages their development (Zampieri, 2004).
Explanatory models of codependency lie within a continuum of severity comprising personality disorders, drug-caused behavior or behavior mainly related to females.In fact, etiology is a multifactorial issue and may be biological, psychological and social.Individual variability, the multiplicity of contrary experiences within a dysfunctional family (with experiences of parents´ conflicts, emotional abuse and abandonment), changes in the perception on female roles and the occurrence of illicit drug abuse may be related to the development of codependency (Knapek & Kuritárné Szabó, 2014).
Codependent behavior originates from feelings of guilt and accountability which, in their turn, makes relatives take the burden on themselves at the expense of their life quality by focusing on the life of the other.Information and understanding of the issue are highly important, since the attitude of the codependent family member may cause several difficulties in the therapeutic process of the drug user.
Since a multidimensional understanding on the abuse of illicit drugs is highly relevant for the development of strategies towards an adequate approach to the problem, current analysis describes the feelings and types of behavior of codependent family members of illicit drug users.

Material and methods
Current descriptive and qualitative study was carried out within the coverage area of one of the 27 Basic Health Units (BHUs) in a city in the northwestern region of the state of Paraná, Brazil.This particular BHU was chosen due to its high number of referrals to the services of the Mental Health Care Network of the municipality, especially in cases of alcohol and drug addiction.
Current study integrates a Project of Education for Work (PET) entitled 'PET Mental Health: Promotion, prevention and recovery/reintegration in Mental Health: A survey on mental patients and their families, especially users of crack and alcohol', funded by the Brazilian Ministry of Health and Education and linked to the Department of Nursing at the State University of Maringá (UEM), Maringá, Paraná state, Brazil.
The selection of relatives who would participate in current research was undertaken by BHU professionals who indicated highly endangered families in their coping with illicit drugs, identified by recurring attendance related to illicit drugs for the users and their families.Fourteen families were chosen, coupled to the relatives who were most involved in the care of the users´ care.Holyoake Codependency Index which evaluated the presence of codependency with regard to three factors: focus on others, self-sacrifice and reactivity, was applied to these relatives.HCI consists of 13 questions with Likert-type scale answers.Scores range between 3 and 15 points with a cutoff point for codependency at > 9.7 (Bortolon, Ferigolo, Grossi, Kessler, & Barros 2010).
Inclusion criteria for family members in the study were: be over 18 years old, live with a family member using drugs, and present codependency behavior identified by the Holyoake Codependency Index.Eight out of 14 relatives had a > 9.7 score, or rather, a codependency behavior.
Data were collected between march and april 2012 by an open interview with the caregivers at their homes, on previously scheduled days and times, taking care that the drug user was not at home.Interviews were recorded with the consent of the participants and later transcribed.The basic question was 'Tell me about your feelings and behavior with a family member using illicit drugs'.
Data collected were submitted to content analysis, theme mode, following Bardin (2011), with three basic stages: 1) pre-analysis; 2) exploitation of the material; 3) treatment of results, inference and interpretation.
The pre-analysis stage involves the organization of material to make it workable by systemizing the initial ideas.Organization comprises four steps: (a) flow reading, or contact with the documents in data collection when the text is known; (b) selection of the documents, or the limitation of what will be analyzed; (c) elaboration of a hypothesis and aims; (d) referral of indexes and elaboration of indexes by cuts in the text from the documents under analysis.
The second phase, or rather, the exploitation of material makes possible or not the richness of interpretation and inferences.It is an analytic description of the textual material collected, with an in-depth study and foregrounded on hypotheses and theoretical references.The third phase consists of the treatment, inference and interpretation of results.The phase comprises treatment of results with condensation and underscoring of information for analysis, featuring inferential interpretations; it comprises intuition, reflexive and critical analysis (Bardin, 2011).
Current study complied with Resolution 466/2012 (Brasil, 2013) of the National Board of Health and the project was approved by the Standing Committee on Ethics in Human Research of the institution (number 721/2011).All participants signed the Informed Consent in duplicate and they were identified with the letter F (for family member), followed by a number indicating the order of the interviews and kinship with the illicit drug user.

Results
Eight subjects participated in the research, namely, six mothers, a grandmother and a father.The results of the interviews were grouped into two categories.
Feelings pervading the daily lives of family members with codependency behavior Caregivers´ reports identified feelings of guilt, fear, shame, grief, sadness and worthlessness in the daily life of the codependent family member.Some family members explicitly stated that they felt guilty of the situation of their drug-addicted family member and probed for reasons to explain drug use, the start and maintenance of drug use and failures in the education/formation of the dependent person or in family-based problems.
[...] I feel guilty; I think I haven't done the right thing when raising him.(F2) When he was eight years old, his father abandoned me and I got another partner, but the stepfather was not really into it; he disliked him.Then the boy began to stay longer outside, out of home.And the neighbor's son was addicted to drugs and began offering.I stayed away from home, to work, and he offered drugs to him.When I discovered, he was already addicted.He was fourteen.Then I feel guilty for having arranged a partner, which was bad for him [...].(F5) I talk to God, did we give him so much freedom?Should I have held him more at home?I'm thinking we could have talked to him, we could have worked close to home, I should not have let him leave.When he left home to work, we were moving away, losing that bond of knowing what he was doing, or not.I feel guilty of all this.(F7) We are aware that we are guilty; we did our utmost; the boy turns into a man and dabbles in inappropriate things.(F1-Father) Suffering follows feelings of anxiety, pain, frustration, sadness and fault due to the situation of the drug user.For instance, fear is very present in the daily lives of these family members and shows itself in several ways: fear of forfeiting objects of the family in the user´s negotiations to obtain drugs and fear of something that may happen with other family members.
[...] I don't know whether I undergo heart surgery.I'm afraid he will sell everything while I'm in hospital (F5 Mother).
I'm afraid because if he keeps consuming drugs, sooner or later someone may appear here.I'm afraid they may do things against my other children, against his daughter that I raise; that´s why I'm afraid.(F1 Mother).
He became somewhat choleric at home.Once he was very crossed, grabbed a knife and wanted to harm people.We had to call the SOS ambulance and the police to take him away.They left him at the Psychiatric Clinic, applied some injections and he became better.He became so well that we were afraid of him (F1-father).
Shame was also reported, mainly because the family members are frequently not aware that the use of drugs is a highly disabling and chronic disease, with terrible effects at the individual and collective level.
My husband has always been a serious, stern and upright man.[...] If someone came and asked how his son was, the ground faded away under him.If it were a disease, he would not be ashamed; since the issue is drugs, well [...].(F4-mother) Nevertheless, despite the perceived emotional distress in family members, feelings of faith and resilience were often still present, with high hopes for the rehabilitation of drug users: We will strive and sail through, God willing ... (F3grandmother) I have faith in God because only He can do all things.(F2-mother) Look, even the Bible is here for him.Because I have faith that one day he will overcome this, I´m sure of that.(F5-mother)

Behavior of codependent family members
Although the consequences of drug use generally involves the whole family, some of its members perceive and feel the situation differently and develop some type of mechanism such as denial of reality, an attempt to control the attitudes of the other, to protect the user and taking over responsibility from others.
In the speeches of F4 and F5 one may perceive the control that the family exerts to care for and protect the drug user.
My husband said he gave up and that he will not run after him anymore.He said the son might die on the street, if he so wished.He padlocked the gate door and told him that if he wanted to come in, he should be home before 22h [...] But I would not let my son sleep outside (F4-mother).
I found out he consumes crack, marijuana and alcohol, so I started watching.I used to leave my job somewhat early and observe him; I was always at his footsteps (F5-mother).
Another way of control over the drug user may be underscored, or rather, when parents fail to seek help in community health services to protect the user from society and its biting commentaries.
We've never sought help at the Health Unit and the people there never came to us [...].We were ashamed to get there and talk our problem.It seems that we, as parents, want to hide the problem; we are aware that everyone knew the facts before we did, but we have this habit (F4-mother) No one helps.Only God.We alone solve the problem.We talk to him but he disobeys [...].(F1-father) When addressing drug users in their environment, the family often ends up paying the debts or liabilities of the users, at great sacrifice, in an attempt to protect them from charges and consequences.This behavior may have important financial consequences on the family: One day we received a letter that his motorcycle had been seized.We borrowed the money and got the motorcycle back, but then he sold it again.About three months, he quit the job and found a new one.He said he left the job hoping that the situation would get better, but I know he left it because of the payments due.[...] Yesterday my husband sent a sick leave to the boy´s employers but it seems they did not like it.They said they will call the Psychiatric Hospital to check.(F4-mother) By taking the responsibilities of the other, the family member takes on a codependency behavior, neglects himself/herself and increases the family´s deterioration.
I never think of myself, only of the other.Sometimes my thought focuses on one, sometimes on the other [...] never on myself.(F2-mother)

Discussion
Although restricted to eight families, results reinforce the fact that the theme under analysis is currently emerging on society´s agenda.It involves care and research, due to the deep damage and consequences that the use and abuse of illicit drugs bring to individuals, on their physical and mental health, on familial interpersonal relationships and friendships on studies and on work.Drug use causes intense suffering to the family and great liabilities to society and to the government since the treatment of drug-dependent people needs a specific approach, with specialized service for treatment in the community and hospital beds, in spite of successive relapses.
These features occur with changes in the family´s daily life, suffering, weariness, financial liabilities, shame, impotence and sickness of its members especially on the main caregivers who are most burdened by the problem.Current research showed that the mother is the main caregiver.
Liabilities are high according to the treatment of the drug-user and to losses and quittance of study courses and jobs since they overburden the family to meet both ends.Moreover, maintenance of drug use and their purchase are expensive since the users require increasingly greater amounts.Since users frequently do not have the means to acquire them, they start selling several objects belonging to the home.Such situation was reported when the family member in current study feared that she would lose money which would be required for her heart surgery.
The family is thus the strategic cross-point of socialization and survival of its members.When one member is not well, a rupture occurs in the usual daily living mores with the consequent destructuring of the established family dynamics.The report of a family member corroborates behavior changes of the codependent individual since it implies in the changes of routine which, for Acta Scientiarum.Health Sciences Maringá, v. 39, n. 2, p. 175-181, July-Dec., 2017 instance, characterize constant vigilance on the drug user.
The above attitudes impact social relationships, psychic commitment and overburdening of the codependent member.The importance of the family´s involvement as requiring care and as coparticipant within the therapeutic context of drug users is clearly revealed.In fact, the major consequences of drug addiction are experienced within the family environment (Reis & Moreira, 2013).
As a prerequisite for survival, the family is a primary socializing institution whose main proposition is to ensure types of behavior normalized by affection, culture and full protection towards its members.From this point of view, children´s illness deeply undermines the self-esteem of parents because they interpret it as a failure in the family system (Medeiros, 2013).The above principles corroborate results in current study since the participants´ reports indicate questionings on the motives that made one of their members become a drug user, denoting guilt and failure in children´s education.
The diagnosis of certain diseases may cause a rupture in the family structure with a break in the family bonds.The members have to experience deep changes in their lives.In current analysis, fear was one of the most felt experiences in the daily life of the family members who reported anxiety on their safety due to the changes in the behavior of the user of illicit drugs, and to their belongings which may be sold by the users to purchase drugs.Moreover, emotional conflicts, depression, doubts on the prognosis and treatment also afflict the family members of the drug user.
The above characteristics bring to the fore the codependency of family members.Sobral and Pereira (2012) report that precisely this aspect interferes in the lives of the family members of the drug user, or rather, the intense psychic suffering involved.
The codependent family member becomes vulnerable in any situation, sometimes feeling guilty for the suffering of the patient and family situation, sometimes believing he/she is a victim of the attitudes of the drug user (Medeiros, 2013).
Codependency therefore interferes with the life of the persons who develop it, notably on their mental health and in their manner in dealing with the addiction of their relative.Its manifestations include suffering, emotional pain and physical and mental illness, reflected in multiple and diverse responses.Further, certain feelings derived from the experience are frequent, including discontent, uncertainty, anguish, depression, anxiety, sadness, hopelessness, loss, emotional burden, overload of tasks, and self-neglect (Lima & Braga, 2012).It must be underscored that participants´ reports comprise all the manifestations mentioned by these authors.They indicate dependency and confirm the correct selection by the application of the HCI scale and individual interview.
Diversity of feelings experienced simultaneously, such as guilt, fear, shame and sadness, were also reported in several studies conducted in different countries (McInnis-Perry & Good, 2006;Daire, Jacobson, & Carlson, 2012;Knapek & Kuritárné Szabó, 2014).They favor the codependency of family members since they interfere in the life of illicit drug users and, at the same time, cause in them an intense psychic suffering.
With this issue in view, several theories have been proposed to clarify the role of family in psychological distress.If, on the one hand, they lead to an understanding of family dynamics as an important tool for the assistance given to the members of this social nucleus, on the other hand, the same theories may label families as balanced or imbalanced (Medeiros, 2013).
Furthermore, most respondents, particularly mothers, tend to shoulder the responsibilities of the user, a behavior that may be related to her specific role since mothers are usually the caregivers.Protection is a way in not permitting the child to suffer any injury as a result of drug addiction.
The predominance of women as caregivers is explained by historically and culturally constructed gender issues which assigns to women several roles such as family caregivers, administration of the household, children and professional life (Marcon, Rubira, Espinosa, & Barbosa, 2012;Knapek & Kuritárné Szabó, 2014).
Due to close proximity, family members of drug users, mostly mothers and wives, are more likely to have codependency symptoms.The prevalence of this population reaches 71% and the main symptoms include feelings of low self-esteem and responsibility in solving problems (Bortolon, Machado, Ferigolo, & Barros, 2013).
It should be underlined that family members believe they are helping the users when actually they act wrongly when they protect them by controlling or assuming their responsibilities.In fact, one of the participants in current research said that the family paid the son´s debts to recover a seized motorcycle, which he later sold to buy drugs with the money.Such behavior contributes towards the maintenance of drug users´ behaviors.There are times when the codependent member must not help drug users, which is extremely difficult for the family since it involves more feelings of fear and guilt (Bortolon, et al., 2013).
Financial and emotional burdens affect families, especially when the drug users are also involved in illegal activities such as trafficking, stealing, robbery and prostitution, which interfere significantly and negatively on the health and functioning of their family (Reis & Moreira, 2013).
Due to experienced difficulties, families start to isolate themselves and, for the sake of their 'good image' and fear of gossip, they move away from the community.The above behavior suggests that internalized stigma affects negatively the life of individuals in proportion to their distancing from social conviviality.Restriction in social networks and life opportunities bring great health consequences, involving worsening in life quality, experiences of psychological angst and depression (Ferreira, Silveira, Noto, & Ronzani, 2014).
Besides the professional help offered by services of the Mental Health Care Network, there are support groups for drug users and their family, In fact, this modality was mentioned by some respondents who reported going to HUs to recover values, possibilities and potentialities.These groups actually promote the sharing of feelings, values and meanings through verbal communication (Lima & Braga, 2012).
For instance, a psychoeducational support group was established in Canada for codependent families to enhance their welfare and reduce the contrary effects of codependency, featuring six 90-minute group sessions during two months.Results showed that family members may benefit from the group and codependency issues decreased (McInnis-Perry & Good, 2006).In current analysis, there were no experiences with participants in therapy groups for family members of illicit drug users.This fact is an important gap in the effective inclusion of the family in mental health care.
Groups favor attitudes of welcome, solidarity, sharing of experiences and the pursuit for more adaptive solutions to problems experienced by people in similar situations.They also promote the formation of a support network in which, through the exchange of ideas and testimonies from participants, the needs for behavioral changes within their families are understood.They actually convince the participants not to expect that only drug users should make changes for their recovery (Gomes, Martos, Cavalari, & Rosseto, 2012).
In spite of the involvement of the Family Health Strategy (FHS) and the Support Nucleus for Family Health (NASF), there is still less than 20% coverage for the population.Furthermore, almost all FHS teams fail to include attention to drug users in the list of their activities (Lima-Costa, Turci, & Macinko, 2013).Besides the low coverage, the emphasis on primary health care in Brazil is still fledging with an incipient organizational structure.Further, FHS health professionals have difficulties in dealing with issues related to drug use, due to lack of information on biopsychosocial factors related to addiction, reproducing biases on illicit drug users.
One of the reports described above revealed that a codependent family member, through shame or bias, avoided sharing and exposing the problems experienced within the family to health professionals.In such circumstances, one should overcome the difficulties in inadequate formation of professionals for attendance of mental health cases and the lack of initiative in looking for families with such difficulties.
The relationship between drug users and their family should be underscored to establish an attention that overcomes the obstacles of the preconceived moral judgments (Barbosa & Souza, 2013).
It is highly important to acknowledge the importance of the family of addicts and its essential role in the recovery process of illicit drug users.The literature suggests that in the illness of chemically dependent persons, one factor, albeit not the only one, which motivates the use of drugs and possible relapse, is related to the inability of the family to deal with the behavior of the dependent.Consequently, it also needs care and follow-up (Gomes et al., 2012).
The interactions between health professionals and drug users triggers indirect interactions with their family.Thereby, the inability of one member affects the others in the familial conviviality.By adopting centered work at the dimension of this human encounter, coupled to the biopsychosocial aspect, health professionals may identify bottlenecks in family life through health educational activities and home visits (Lima & Braga, 2012).
Mental Health care and the elaboration of public policies within the context of drugs and their impact on the health of the users, their families and the impacts on social and economic commitment are actually a highly relevant challenge.

Final considerations
Relatives living with an illicit drug user, especially those with codependency behaviors, need professional help to deal with feelings and behaviors experienced in their daily lives.These situations may impair relationships with users and make difficult their development.
Acta Scientiarum.Health Sciences Maringá, v. 39, n. 2, p. 175-181, July-Dec., 2017 The daily practices of health professionals must take into consideration the situation of families with a member doing drugs and provide a consistent care to their real needs.One must underscore that families should be assisted differentially, with the identification of family members with codependency behavior since they also require specific care so that their inconveniences would not develop into a clinical or psychiatric diagnosis.It is therefore necessary to promote and encourage the participation of families in support groups and, at the same time, promote a professional practice that offers care directed to family members.A favorable environment for welcome and listening is provided, approaching persons and promoting exchange of experiences especially among families.
But I know it's not easy, not easy [...] I see that boy [...] I look at that picture of his first Holy Communion and I do not recognize him anymore.No one imagines the pain that we feel.(F4)