The experiences of family members attending an online addiction education program: a qualitative study

Abstract

Family members of people experiencing addiction may experience increased stress and have difficulty coping with disrupted relationships, stigma, and isolation. Education programs for affected family members aim to assist in improving coping skills, understanding of addiction, and provide support, yet these have not been subjected to in-depth research, especially programs delivered by peers, or people with lived experience. This study explored the experiences of participants attending a BreakThrough online group education and support program for family members of people experiencing addiction. Twenty-one affected family members were interviewed and reflexive thematic analysis was used to develop three themes: experience of validation; not fixing, stepping back; and, education to help make sense of experiences. A topic summary was used to present data relating to the experiences of attending online. Participants experienced the group as validating and de-stigmatizing, thereby helping shift their approach to coping and consolidating their understanding of addiction. Participants reported being able to harness the collective insights of peers and make sense of their experiences through education and support. Education programs for affected family members, facilitated by peers, provide an opportunity for validation and ultimately serve to de-stigmatize addiction.

Keywords:

• Addiction
• drug education
• family intervention
• qualitative research

Introduction

Family members who support a loved one experiencing addiction face many challenges, including disrupted family relationships, stigma from within the family and the community, and social isolation (Copello et al., 2005; Corrigan et al., 2006; McCann et al., 2017; McCann & Lubman, 2018a; 2018b). As a result, affected family members often experience increased levels of stress and difficulty coping, negatively impacting their health and wellbeing (Copello et al., 2005; McCann et al., 2017; 2021; McCann & Lubman, 2018a; 2018b). While affected family members adopt a range of coping strategies to help support their relative and manage their own health and wellbeing (McCann & Lubman, 2018; Wilson et al., 2019), many report experiencing multiple challenges in accessing evidence-based information (McCann et al., 2019).

Two recent reviews of programs for affected family members highlight their potential for improving coping skills, substance use and addiction literacy, and feelings of connection and support (Kourgiantakis et al., 2021; Merkouris et al., 2022). These programs may also have flow on benefits for the relative experiencing addiction, including improved relationship functioning and reduced distress (Kourgiantakis et al., 2021; Meads et al., 2007). However, research focusing on family-focused programs where peer support is a core element is limited.

Involvement of people with lived experience, or peers, has grown within the treatment system for people experiencing addiction (Eddie et al., 2019; EÉk et al., 2020). Programs delivered by peers, or with significant peer input, have a positive impact for people experiencing addiction (Bassuk et al., 2016). For affected family members, few studies have reported on the role of peers in delivering programs. Kelly et al. (2017) reported on one peer-led support organization for affected family members in the US, where participants attended regular in-person meetings supplemented by online resources. The participants reported gains in understanding and coping, felt better able to help and communicate with their loved one, and reduced self-blame and stress (Kelly et al., 2017).

The use of technology in facilitating programs for affected family members is increasing. Two studies included in Merkouris et al. (2022) meta-analysis of psychosocial interventions involved online provision. One provided Community Reinforcement Approach and Family Training (iCRAFT) (EÉk et al., 2020), and the other provided coping skills training (Rychtarik et al., 2015), both to affected family members supporting loved ones with alcohol use disorder. Participants reported short-term improvements in depressive symptoms, quality of life, and relational happiness (EÉk et al., 2020); and improved coping skills, depressive symptoms, and situational anger (Rychtarik et al., 2015). However, both programs were therapist-led without an element of peer involvement.

There is a need for more research focusing on programs for affected family members using qualitative methods (Copello et al., 2005; Kourgiantakis et al., 2021). Qualitative approaches are essential for exploring participants’ experiences, allowing for an in-depth understanding of a person’s perceptions and behaviours, and the meanings they attach to their experiences (Pope et al., 2002). To our knowledge, no qualitative analyses of experiences of family-focused psycho-education programs have been conducted to date.

This study reports on the experiences of participants attending an online group education and support program for family members of people experiencing addiction. Our aim was to explore their experiences of attending the group, specifically, our primary research question was, how does participation in this program influence participants’ knowledge of, and ability to cope with their loved one’s addiction? Given the move to online program delivery in response to the COVID-19 pandemic, our secondary research question was, how do participants experience the program and connect with others online?

Materials and methods

Established in 2015, BreakThrough is a peer-led, group education program for families, friends, and partners of people with addictive behaviours, based in Victoria, Australia. BreakThrough is delivered every two weeks, either in person at local community centres, or online via Zoom, by: (i) the Self Help Addiction Resource Centre, a community-based mutual self-help organisation providing family support, consumer participation, and peer-based recovery support for people experiencing addiction; in partnership with, (ii) Turning Point, a national addiction treatment, education, and research centre. Based on the Stress-Strain-Coping-Support (SSCS) model (Copello et al., 2000), BreakThrough provides evidence-based and practical information on substance use, communication, coping strategies, family violence and safety, and self-care, as well as resources to enable participants to access additional support. BreakThrough participants register their attendance for individual sessions via a website (https://www.breakthroughforfamilies.com/).

Since 2015, the program has been delivered to over 5,000 people across Victoria, with approximately 50 sessions delivered each year. Originally designed as a face-to-face program, BreakThrough was adapted for an online setting in response to COVID-19 restrictions, allowing for greater participation from people not able or willing to attend in person. Each session has two facilitators, both of whom hold qualifications in alcohol and/or other drugs, and one who has lived experience of supporting a family member experiencing addiction. Each session is one hour with facilitators presenting information and strategies, and providing opportunities for attendees to discuss and comment based on their experiences, if they wish. Sessions can cover various topics throughout the year, however, six core topics are regularly available: (i) understanding addiction; (ii) mental health, (iii) family relationships; (iv) boundaries and safety plans; (v) communication; and, (vi) recovery. Attendees are free to attend one, several, or all sessions, or re-attend sessions, depending on their interest.

BreakThrough registration data indicates that, on average, 17 people attend each session: 86 per cent of attendees are women and 41 per cent attend as a parent of someone experiencing addiction. Internal BreakThrough feedback indicated that attendees found BreakThrough to be beneficial, were satisfied with the content, and would recommend it to others. However, this data did not indicate how, and to what extent, attending BreakThrough impacted on the ability of attendees to cope and provide support to their loved one.

We used convenience sampling to select potential participants in this study who were family members, friends, or partners of people experiencing addiction, who had recently attended one or more BreakThrough sessions online, and were available to be interviewed via telephone within the three month period of data collection. Due to the qualitative nature of this research, there was no need for sample size or power calculation estimates. Information about the research project and a link to an online expression of interest form was shared with BreakThrough attendees by program facilitators, at the end of each BreakThrough session, during the recruitment period (July-September 2021). We e-mailed potential participants who expressed interest in the project the participation information sheet and arranged an interview time. Participants had the opportunity to ask questions and provided informed consent at the start of the interview. Participants were offered one $50 supermarket voucher as an incentive for completing the interview.

We developed a semi-structured interview guide consisting of open-ended questions based on our research aims and analysis of feedback form data (Appendix 1). Author 1 (AP) and Author 2 (FH) conducted the semi-structured interviews by telephone, between July and December 2021. The interviews were recorded using a digital audio recorder. The recordings were transcribed verbatim by a professional transcription service.

After reviewing the transcripts of three interviews, AP and FH reflected on the interview structure and flow, and adapted the questions in the guide as required. AP and FH also used field notes captured at the end of each interview in the form of a contact summary sheet, to capture impressions and reflections on the interview (Miles & Huberman, 1994).

Each participant was interviewed once. Interviews ranged from 15 to 35 minutes, with an average interview time of 24 minutes. At the end of recruitment, 30 potential participants had expressed interest in completing the interview. Two declined to participate, and seven were unable to be contacted or able to schedule an interview during the time allocated for data collection. The remaining 21 participants were interviewed for our study.

We used an incremental approach to saturation, whereby at the completion of interviews we considered whether more information would be useful to address our aim and research questions. Through this process, we decided further data collection was not required after interviewing 21 participants (Saunders et al., 2018).

We used Braun and Clarke (2022) reflexive thematic analysis (RTA) approach to analyse the interviews. Given the limited literature on affected family members’ experiences of programs such as BreakThrough, this approach was considered appropriate as it allowed for a primarily inductive approach, in which we could explore both semantic and latent ideas in the dataset, and provide descriptive and interpretative accounts of the data.

Braun and Clarke (2022) describe RTA as a recursive process involving six phases: (i) data familiarisation, (ii) coding, (iii) generating initial themes, (iv) developing and reviewing themes, (v) defining and naming themes, and (vi) writing up. First, FH checked all transcripts against their audio-recording for accuracy, and wrote preliminary notes. The transcripts were entered into NVivo (QSR International Pty Ltd, 2020; Rychtarik et al., 2015) to assist with managing the initial coding process. The transcripts were divided between AP and FH and each produced initial codes. After discussion, AP and FH agreed on primary codes, and all transcripts were re-coded with these codes. AP and FH generated initial themes and used thematic mapping to develop and review these. FH used Microsoft Excel to manage the initial themes, then defined and named the themes, discussed these with AP to clarify themes, and wrote up the findings. All participants were given participant IDs and pseudonyms to protect their anonymity.

For this research we employed a number of processes to ensure analytical rigor, guided by Yardley’s (2000) criteria for quality in qualitative research. Yardley (2000) reported four characteristics of good qualitative research: sensitivity to context, commitment and rigor, transparency and coherence, and impact and importance. To address these criteria we: used a sufficient sample of interview data to show density of evidence for each theme; collected and analyzed data over a number of months, enabling long-term engagement with the data; and met frequently during data analysis to progress theme development.

This research was carried out according to the National Statement on Ethical Conduct in Human Research (2007). This research was approved by the Monash University Human Research Ethics Committee (MUHREC; Application ID: HRE29-407; Approval Date: 28/06/2021).

Results

Participant characteristics

All of the participants were female, with an average age of 53 years (SD = 10.5, range 37-74 years). Most (n = 14, 67%) participants lived in urban areas, while eight lived in regional towns or rural areas. None of the participants reported identifying as an Aboriginal and/or Torres Strait Islander. The most common primary drug of concern for participants was methamphetamine/ice (n = 8, 38%), followed by alcohol (n = 4, 19%), and poly-substance use (n = 4, 19%). Most participants supported their child (n = 16, 76%) or a partner or ex-partner (n = 4, 19%), for an average of 5.4 years (range 2 months to 17 years). Participants had attended an average of 4.5 online BreakThrough sessions (SD = 1.28, range 2.5-6). Table 1 provides further information on participant characteristics.

Table 1. Participant characteristics.

Characteristic	Number (%)
Age (years)
30-39	3 (14.3%)
40-49	4 (19.0%
50-59	8 (38.1%)
60-69	5 (23.8%)
70-79	1 (4.8%)
Gender identity
Female	21 (100%)
Male	0 (0%)
Geographic area
Metropolitan	14 (66.7%)
Regional	5 (23.8%)
Rural	2 (9.5%)
Relative’s primary drug of concern
Methamphetamine/ice	8 (38.1%)
Alcohol	4 (19.0%)
Poly-substance	4 (19.0%)
Cannabis	3 (14.3%)
Heroin	1 (4.8%)
Prescription drugs	1 (4.8%)
Relative’s relationship to participant
Son	13 (61.9%)
Partner or ex-partner	4 (19.0%)
Daughter	3 (14.3%)
Friend	1 (4.8%)
Length of time supporting relative (y)
<1	3 (14.3%)
1-2	2 (9.5%)
2-5	6 (28.6%)
5-10	6 (28.6%)
10-20	4 (19.0%)

Themes

Through our analysis of the 21 interviews, we developed three themes: (i) Experience of validation; (ii) Not fixing, stepping back; and, (iii) Education to help make sense of experiences. We also produced a topic summary, ‘Attending online’, to summarise participants’ experiences of attending BreakThrough online. The characteristics of the themes and topic summary are shown in Table 2.

Table 2. Summary of interview themes and topic summary.

Theme name	Summary of theme
Experience of validation	The validating and de-stigmatising impact of the program, created through the program’s education and peer connection.
Not fixing, stepping back	Experience of reflecting critically on their approach to their relative’s substance use, and their efforts to change from a ‘fixing’ approach to a ‘stepping back’ approach.
Education to help make sense of experiences	BreakThrough's role in meeting the urgent and fundamental need expressed by participants to gain education and knowledge about addiction, in order to make sense of their experiences.
Topic summary: Attending online	Summary of participant experiences in attending BreakThrough online.

Theme 1: Experience of validation

The first theme, ‘Experience of validation’, explains how attending BreakThrough facilitated changes in participants’ feelings and beliefs, a process they described as validating and de-stigmatising. Participants’ emphasised the impact of seeing their decisions, emotions, and experiences recognised as normal and valid through BreakThrough educational messages and peer facilitators and attendees. While participants described various instances of validation achieved through attending BreakThrough, many accounts centred on their self-image as ‘normal’ people and ‘good’ family members. For example, in the excerpts below, two participants described concerns that they are not ‘good’ parents by using ‘tough love’ or having ‘done something wrong’ that were nullified by their attendance at BreakThrough:

It’s helped me feel validated and reassured as a mum that sometimes tough love is what’s needed and I'm doing the right thing, even when there’s conflict […] I didn’t really believe that before I did BreakThrough because everybody I know has not had this kind of experience […] I was going by my gut and I wasn’t always sure my gut was right so this helped me feel empowered, I suppose would be the word, and reassured that I was doing the best with what I had and that I wasn’t alone. There are plenty of other regular looking parents out there that are going on with this sort of stuff. Diane, 46, mother

That first session talked a lot about causal factors, and I think, from a family member’s perspective, it was good to hear that it was quite normal for families to say what have we done wrong? But it’s actually not what we’ve done wrong. Benita, 56, mother

Peer contact served to validate and normalise their experiences. Sally and Genevieve echoed Diane’s insights, that many ‘regular looking’ people are sharing their situation:

You tend to not discuss things with family or friends because of the stigma around it, so you tend to try and keep it on the low down to yourself. But when you do go in a group like that, it’s very helpful because you realise there’s - it’s not just you in that situation, there’s a whole lot of other people. Sally, 65, mother

I felt very alone in what I was going through and ashamed that this is what I was going through. I just didn’t realise at the time that so many others were experiencing the same thing. I suppose that’s because I didn’t talk about it at the time. I was really embarrassed to share with others, so doing the BreakThrough really made me become more open and honest and share with people about what was happening. So I don’t feel ashamed anymore. Genevieve, 49, mother

Stigma and de-stigmatisation were explicitly and implicitly linked with participants’ accounts of validation. Participants were aware that the general public often judged people experiencing addiction and their families, and that others view family members as causing their relative’s addiction or contributing to its continuation. In the excerpts below, Genevieve and Liz describe their shift from acceptance to rejection of stigmatising beliefs about addiction, resulting from their involvement in BreakThrough.

I always felt such a responsibility in it all, and I blamed myself […] [My son] said to me, “It’s not you, mum. Don’t blame yourself, let that go”, and I've never been able to, but I think doing BreakThrough has really helped me release a lot of that. I don’t know, it just got through to me that it’s not just me. Genevieve, 49, mother

The resources and the information that was put across in that session really helped me to understand or step back from it, to step back from feeling responsible or driving him to use, that side of things. Liz, 37, ex-partner

While BreakThrough's primary aim is to provide education and strategies, the contact with others who shared their experience of supporting a relative with addiction was also described as validating and de-stigmatising. Participants described their first experiences as isolating, in which stigma and misinformation made talking to friends or family difficult.

Theme 2: Not fixing, stepping back

The second theme, ‘Not fixing, stepping back’ captures participants’ conceptualisation of two core approaches to supporting their relative (‘fixing’ and ‘stepping back’), and their experiences of attending BreakThrough, that allowed them to reflect critically on their use of these approach(es). Theme 2 also describes participants’ ongoing efforts to move from the negative ‘fixing’ approach to the positive ‘stepping back’ approach. Theme 2 expands on the concept outlined in Theme 1 that attending BreakThrough helped support a shift in participants’ thinking. Participants consistently described their past ‘fixing’ approach in negative terms, as attempting to control and fix the circumstance, course, and impacts of their relative’s substance use, resulting in distress, guilt, and conflict for themselves and their family. In the ‘stepping back’ approach they aspired to, participants described establishing boundaries, accepting their limited control over what happens, and allowing their relative to bear the consequences for their actions. Notions of control were important in both approaches, with ‘fixing’ framed as acting like the ‘control freak’ and feeling ‘all over the place’, while ‘stepping back’ was framed as both relinquishing control and regaining control, as described in Sally’s excerpt below.

Before I would be angry, accusatory, blaming […] I was all over the place. I really didn’t know honestly how to deal with him […] so for me BreakThrough gave me clearer strategies to step back and just let him in a way, work it out […] you really have to change the way you think and that’s what has happened to me. I’ve changed the way I think. Sally, 65, mother

Jill describes similar sentiments as Sally, shifting her attitude from a stressful past approach trying to fix her relative’s addiction, to recognising ‘there’s nothing you can do’, the relative must ‘want to fix it’: ‘I was probably making the situation worse for myself, because of the stress, and just not - trying to be the control freak, trying to fix it, and it wasn’t working.’ Later, Jill elaborates:

… it’s more just about the whole acceptance of, this is what’s going on, and there’s nothing you can do that’s going to fix it, really. You can support, but you’re not going to be able to fix the problem unless they want to fix it. Jill, 57, mother

The theme ‘Not fixing, stepping back’ also captures the challenges of enacting and maintaining this change, as articulated by participants. Adopting new strategies and changing coping approach was described as emotionally challenging, with participants depicting their current strategies and approaches as imperfect and needing further work. Fiona spoke of the usefulness of BreakThrough and how the content made sense, ‘but it’s the emotional aspect of actually being able to follow these strategies’. This was clarified further by Benita:

Things like learning to let go and not wanting to fix the issue, because it’s not necessarily fixable. I haven’t stopped, but I’m not as full-on in action mode and needing to come up with solutions on behalf of my son. But I certainly have stepped back from that. Benita, 56, mother

BreakThrough was described as helping participants recognise these approaches, define boundaries, cement their commitment to change, and learn and use effective strategies. It was a means for participants to understand their own behaviours and approach and identify ways to enact the ‘stepping back’ change they wanted.

I was treating my 32-year-old son like a child, which I know – and through BreakThrough I learnt that happens a lot, when someone becomes an addict, because you feel like you’ve just got to help them all the time […] I realised that I had to stop that. Ellen, 53, mother

… particularly in the boundaries [session] it was giving the right words to say because I think you are always, as a family, you are always treading on eggshells. So, there were many points in that session of how to use the right words. Where you can gain the person’s confidence that you are stepping back and making them deal with their own problem. You won’t keep stepping in for them because that’s just detrimental along the way. Julia, 63, mother

Theme 3: Education to help make sense of experiences

Theme 3 refers to participants perceiving BreakThrough's role in meeting their urgent and fundamental need to learn about addiction, to make sense of their experiences. In their descriptions, participants came to BreakThrough feeling they did not possess the skills or knowledge to respond effectively to, or cope with and process, their experiences. Ellinor spoke of not having a clue about ‘how to proceed or what to do with all of the thoughts and feelings that I had’. Nicole described the need in emotive terms in recognition of the sudden impact of addiction on her family: ‘I wanted factual information. I didn’t want someone to go “there, there, isn’t this horrible” […] I just want to know everything. I want to know everything about what’s happening to my beautiful boy.’

Acquiring information and skills was the primary driver in participants’ decisions to attend the program and was necessary to process, understand, and cope with the addiction and its related impacts. In participants’ accounts, BreakThrough met this need for information and skills specific to their circumstances as family members. Ellinor explained her experience when she arrived at BreakThrough: ‘I didn’t really know what to do. I needed maybe some advice or some assistance […] I really felt backward and hopeless. I was just like; I have no idea what to do with this information [that relative was using ice]’. Similarly, Fiona was looking for sense-making of her experiences:

I was looking to get out some tips or some answers to the questions on how to understand the behaviour of a person who’s addicted. Because to me, in my rationale, these behaviours don’t really make sense […] I was looking for something that would help me understand why such behaviours, and how to understand them and how to deal with them. Fiona, 30s, partner

Ellinor and Fiona also describe the emotional impact of the addiction and their need to ‘make sense’ of what was occurring through guidance and education, which they identified as provided by BreakThrough. Ellinor went on to acknowledge the education provided hope, new insights and understanding, and confidence in decision-making:

… it’s been a really helpful tool for me and I think for so many people it gives them some sense of hope and - I don’t know, maybe control or understanding that wasn’t there previously […] they’ve given me a lot of confidence. A lot of understanding about the kind of decisions that maybe I should be making and the way that I can approach this. Yeah, a complex issue that’s now a part of my world. Ellinor,30s, partner

Finally, education to make sense for Genevieve became not just a turning point in their understanding, but an opportunity to educate others about addiction, potentially de-stigmatising addiction within their broader family:

… it helped me understand what addiction is, how it impacts the brain and how powerful it is and how it’s such a difficult thing to overcome […] it just helped me understand more why and how it all works. So now, when people say that to me, like some of my family say - or others will say, ‘why can’t he just stop?’ It’s like, I can explain why, or I say, ‘look, why don’t you come do this at BreakThrough? This will explain to you exactly how it all works. I can guide them […] I've got a point of reference to say this will help you understand. Genevieve, 49, mother

Topic summary: Attending online

As this program was originally conducted face-to-face, we were curious to hear participants’ experiences of attending BreakThrough online (our secondary research question). We present their perspectives as a topic summary (Braun & Clarke 2022), as it consists of a summary of the data relating to the online setting, rather than a developed theme.

We found that overall, participants indicated a preference for the affordances and conveniences of the online setting. In particular, they described a number of barriers that would prevent them attending a face-to-face program, including geographic barriers, family and parenting obligations, supporting their relative, and work. Participants also described the online setting as non-threatening, especially for new attendees, as they could turn their camera off, use the chat function, or just log in and listen, choosing their level of involvement and anonymity. Several also noted additional online positives, such as being able to log on via phone or computer from any location, and the mute function, which allowed the facilitators to present without interruptions or distractions. Importantly, many participants reported their own technology skills as poor when describing their experience of ease and convenience attending online. Despite the overall preferences for online attendance, some also described face-to-face as a warmer experience, which allowed for a greater sense of connection than can be achieved online.

I’m sure that the in-person sessions would be really wonderful, but I know from my point of view, it’s incredibly hard to get to these things. Just transporting yourself across [large city] to do it is very tricky, to get there on time without taking time off work and obviously like a lot of people with children and things with addictions, your time is so sucked up by all sorts of other problems that there’s just hardly any left. Ellen, 53, mother

It’s very new for me. So to be able to ease in and be anonymous to begin with, it feels really comfortable. Ellinor, 30s, partner

Considering I’m 65 and not really switched on with all that [online] stuff, I thought that it was very easy for me. Sally, 65, mother

… being physically present there gives a different level of connectedness. Fiona, 30s, partner

Discussion

Our aim was to understand the experiences of people who attended BreakThrough, a peer-led group psycho-education-based program for affected family members of people experiencing addiction. We interviewed 21 BreakThrough attendees and interpreted their experiences via three themes: BreakThrough as validating their experiences and de-stigmatising addiction (‘Experience of validation’); participants reflecting critically and changing their approach (‘Not fixing, stepping back’); and BreakThrough as meeting an urgent need for education and knowledge, to help participants make sense of their experiencers (‘Education to help make sense of experiences’). We also summarised their perspectives on the online setting of the program.

Our findings that participants experienced BreakThrough as validating and de-stigmatising highlights the central importance of stigma and misinformation in affected family members’ experience of supporting a relative. Participants described two key shifts in thinking connected to their attendance at BreakThrough: a shift in stigmatising beliefs about addiction, and in their approach to coping with and managing their relative’s addiction. Specific topics in BreakThrough, such as factual addiction information, learning about boundaries and self-care, and connecting with lived experience facilitators and attendees, seemed to consolidate participants’ new de-stigmatising beliefs and new ‘stepping back’ coping approach.

Our study highlighted the impacts of stigma on affected family members, consistent with previous literature (McCann & Lubman, 2018a). Participants expressed awareness of public stigma (i.e. society’s negative beliefs and responses toward people experiencing mental health problems, and their family and friends [Corrigan et al., 2014]), as well as the three modes of self-stigma, (i) acceptance of stigmatising stereotypes, (ii) application of stereotypes to themselves, and (iii) stereotype-related self-devaluation (Corrigan et al., 2006, 2014). Public stigma awareness and self-stigma were evident in participants’ self-doubts around their decision-making and need to feel their decisions, in particular, to ‘step back’, care for themselves, and set boundaries, were valid and defendable against social judgement. Acceptance, application, and self-devaluation related to public stigma were also evident in participants’ fears of being a ‘bad’ family member, whether they caused or contributed to the addiction, and fear of social exclusion due to their relative’s addiction (Theme 1; Corrigan et al., 2006, 2014; Orford et al., 2013). While we provide further information on how families experienced and coped with stigma, we also suggest that engaging in programs such as BreakThrough may help alleviate the impacts of public stigma on affected family members and reduce their levels of self-stigma. Our participants indicated that, beyond providing practical skills and addiction education, attending BreakThrough helped facilitate a change in their beliefs that allowed them to adopt a more positive self-image related to their identification as a family member of someone experiencing addiction, increasing their self-esteem and well-being.

Participants perceived two opposing approaches to coping with their relative’s substance use (Theme 2: ‘fixing’ and ‘stepping back’). This aligns with previous research on affected family members’ coping styles, such as ‘holding on’ and ‘letting go’ (Maltman et al., 2020) and ‘standing up’/engaged coping and ‘withdrawal coping’ (Horváth & Urban, 2019; Orford et al., 1998). Maltman et al. (2020) analysed online counselling transcripts of parents of adult-children with methamphetamine use problems and identified two coping approaches: ‘Holding on’ where parents attempted to control, monitor, and improve their adult-childs’ behaviour and circumstances, which was often detrimental to the parents’ needs; and, ‘letting go’ where parents released control and let their adult-child take responsibility, which was emotionally difficult but allowed parents to prioritise their own well-being. These two approaches were not mutually exclusive, although participants often described ‘holding on’ before attempting to ‘let go’, as in our themes (Maltman et al., 2020). Two of the three SSCS model coping approaches were also broadly similar: ‘standing up’/engaged coping, where affected family members tried to change a relative’s substance use in emotional, assertive, controlling and/or supportive ways, and ‘withdrawal coping’, where affected family members withdrew from the relative or engaged in activities independent of the relative (Horváth & Urban, 2019; Orford et al., 1998; 2013). The third SSCS model approach, ‘putting up’/tolerant–inactive (affected family members accept substance use and make sacrifices in the face of it or encourage it) may not have been identified in our or Maltman et al. (2020) sample. This may be because affected family members using that coping style may be less likely to seek out online counselling (Maltman et al., 2020) or education programs such as BreakThrough.

In Maltman et al. (2020) themes, ‘fixing’/‘holding on’ was the dominant approach, with the majority of participants showing limited awareness that their needs were being overlooked. In our sample, most participants described ‘fixing’ as ineffective and detrimental to their and their relative’s well-being, and talked about conscious efforts to ’step back’. This difference may reflect our participants’ internalisation and acceptance of the boundary-setting and self-care messages promoted in BreakThrough. These results suggest that, among those who seek out assistance, either through psycho-education programs or online counselling, ‘fixing’/‘holding on’ and ’stepping back’/‘letting go’ may be common coping approaches used by affected family members. A program such as BreakThrough may help affected family members make conscious decisions about how to manage and cope with their relative’s addiction. Further research is needed to understand the experiences and needs of affected family members who do not engage in support and may be using other coping approaches, such as a the SSCS-model ‘putting up’/tolerant–inactive approach (Orford et al., 1998; 2013).

Our themes pertain to attendees of one type of psycho-education-based group delivered in Victoria, Australia, so do not reflect the experiences of all affected family members. However, our aim was to explore the affected family members’ experiences of BreakThrough, in a way that captures a rich and context-specific account. We did not collect data on participants’ cultural identity, apart from whether they identified as Aboriginal and/or Torres Strait Islander. Our sample were all women and predominantly mothers of adult-children experiencing addiction, and is therefore unlikely to reflect the experience of other (for example, male) family members, or all family members attending BreakThrough. This sample, however, did reflect a diversity of primary substances of concern, including methamphetamine/ice (n = 8), alcohol (n = 4), poly-substance (n = 4), and cannabis (n = 3). In addition, this sample reflects the characteristics of BreakThrough attendees and is also consistent with other research in which help-seeking affected family members were predominantly women (Maltman et al., 2020; Orford et al., 2013; Wilson et al., 2018, 2019;). Further research is needed to understand whether these experiences are shared by men and by other family members, as well as raising the question of how we can better support male family members to ask for and receive support.

A second limitation is that, while some participants attended past face-to-face BreakThrough sessions, all chose to attend online when BreakThrough was online-only due to COVID-19 lockdowns. These participants’ experiences of the online setting may differ to those who attended face-to-face or may have chosen not to attend due to the online-only option. Given increased availability of online programs post-COVID-19, it is important to understand how such programs are experienced by family members. In addition, future research with offline BreakThrough attendees may help clarify whether these themes are consistent with the experience of attending the face-to-face program.

Affected family members attending an online psycho-education-based program about their relative’s addiction were able to harness the collective insights of peers and make sense of their experiences through education and support. Poor community understanding about addiction and high levels of stigma and misinformation may negatively impact affected family members in their ability to cope, feel self-assured in their decision-making, and maintain a positive self-image and identity, while supporting a relative experiencing addiction.

Programs such as BreakThrough provide an avenue for validation and ultimately serve to de-stigmatize addiction. The BreakThrough program has important implications beyond just the sharing/teaching of practical skills and strategies, in that it helped participants to shift their beliefs and approach in supporting their relative.

For programs with an education focus, incorporating peer support and experiences of validation help participants make sense of their experiences and understand addiction. These elements are useful to include and for program developers to consider in the design and implementation of similar programs.

The online setting was received positively by participants, and, despite describing themselves as lacking computer skills, they expressed a strong preference for continuing an online option for the program. Program developers are encouraged to include an element of online delivery to accommodate the needs and preferences of participants, and reduce geographic and social barriers to participating in programs.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work was supported by the Alcohol and Drug Foundation under the Information Services and Support (Family and Friends) Grant Program.