How affected family members communicate about their loved one’s non-medical opioid use

Abstract

Family members of people who misuse opioids frequently experience stigma due to their association with non-medical opioid use (NMOU). Stigma may affect how family members communicate about NMOU and seek social support. Guided by communication privacy management theory, this study sought to understand how affected family members (AFMs) communicate about NMOU within and outside of the immediate family. In-depth interviews were conducted with 34 adults with an immediate relative with NMOU. Qualitative analyses utilized a common iterative approach. Findings identified complex dialectical tensions that families traverse in both wanting to conceal stigmatizing information while simultaneously wanting to disclose information to engage support for themselves during stressful experiences. Strategies to resolve this tension included focusing on the good, functional updates, and moving from closed to open communication boundaries. Treatment for individuals with NMOU should engage families and assist with the resolution of communication privacy management tensions.

Introduction

Research confirms that close family members of people who use opioids are deeply affected by their loved one’s opioid use and the consequences of that use (Sharma et al., 2019). Almost half of US adults have reported that substance use by an important family member has caused emotional, physical, financial and/or interpersonal distress within their family (McCann & Lubman, 2019; Saad, 2019). Among affected family members (AFMs), nonmedical opioid use (NMOU) causes physical and emotional distress, creates financial hardship, and generally disrupts family life (Nebhinani et al., 2013). As a result, family members of people with substance use problems demonstrate increased rates of depression, anxiety, stress, trauma, and suicidality (Mylant et al., 2002; Ray et al., 2009; Richter et al., 2000). Though social support has been shown to be beneficial for AFMs (Friedrich et al., 2023; Kelly et al., 2017), the stigma associated with NMOU often deters help-seeking and drives isolation (McCann et al., 2019; McCann & Lubman, 2018).

Family members, like people engaged in NMOU, are affected by stigma toward NMOU via courtesy stigma (Goffman, 2009), or stigma by association. Family members are often blamed for both the onset and resolution of their loved one’s substance use problem (Corrigan et al., 2006; Pasman et al., 2023). Public stigma translates to feelings of embarrassment and shame among AFMs (McCann & Lubman, 2018; O’Shay et al., 2023; O’Shay-Wallace, 2020) and culminates in a host of poor outcomes. Among AFMs, stigma experiences are linked with physical and mental health problems (Song et al., 2018), emotional and relational issues (Ellis et al., 2020), and poor quality of life (Park & Park, 2014). The well-being of family members can in turn affect their loved one’s recovery efforts (Rowe et al., 2012).

Family Systems Theory (FST; Goldenberg, et al., 2017) offers a framework to guide this study and explain the reciprocal influences that family members have on one another. FST maintains the interdependence of individuals within families as circumstances (such as NMOU) within one family member will have repercussive effects upon other family members and the whole family system. Patterns and rules, often unspoken, regulate and determine family members’ behavior both internal and external to the family system, including communication with others within and outside of the family (Galvin et al., 2005). Such rules also regulate what information can be shared with whom and under what conditions. This is especially true for the communication of information that may be considered secret, personal, or in some way stigmatizing-such as a family member’s NMOU. Closely related to rules are family boundaries which regulate the flow of information between individuals within the family and between the family and those outside of the family system (Galvin, et al., 2005). These boundaries may be (a) rigid: offering little opportunity for information sharing; (b) diffuse: offering few limitations to what is shared with whom; and (c) flexible: with greater nuance to what is communicatively shared and not shared within and outside of the family.

Drawing on FST (Goldenberg, et al., 2017), communication privacy management theory (CPM; Petronio, 2002) focuses more precisely on communication and informational boundaries that allow individuals to carefully choose with whom they communicate information and what information is communicated. According to CPM, the use of informational boundaries allows individuals to manage the dialectical tension that exists in the opposing desires to both reveal information to others and to conceal information from others. How families communicate about a loved one’s NMOU will be determined in part by family rules that dictate the level of rigidity or diffusion of informational boundaries within and outside the family system. Due to stigma surrounding NMOU, having a loved one with NMOU may increase the dialectical tension between the desire to reveal information, in order to generate support from others, and the need to conceal information, to protect family members from the consequences of stigma.

According to CPM, privacy rules maintain informational boundaries and are informed by multiple factors such as gender roles, cultural values, motivation, risk-benefit factors, and contextual issues (Petronio, 2002). Eventually, individuals develop their privacy orientation somewhere on the dialectic between lower permeability (rigid or guarded) and higher permeability (uninhibited or diffuse). Privacy orientation shifts however depending on the information one has to share and the larger culture’s perspective on that information. Therefore, the dialectic between lower and higher boundary permeability may be negotiated differently depending on the intensity of the individual’s need for support (motivation) and the potential negative consequences of disclosing, termed “risk-benefit analysis” (Petronio, 2002). CPM is an appropriate lens through which to examine family communication about NMOU as culturally generated stigma surrounding NMOU often forces families to reconsider and renegotiate their privacy boundaries.

Previous research using CPM has examined information privacy management in multiple contexts. Lewis et al. (2011) examined patient/physician communication about birth control through the lens of CPM and identified both patient characteristics and physician characteristics that determined the permeability of patients’ privacy boundaries. Similarly, Walrave and colleagues (2022) used CPM in their examination of communication boundaries between parents and adolescents related to social media sharing, and identified strategies that parents and adolescents developed to negotiate privacy boundaries and avoid boundary turbulence. Another study using CPM to examine boundary negotiation about what, when and with whom to share information about a lung cancer diagnosis identified the importance of risk benefit analyses to accessing social support (Ngwenya et al., 2016). No previous studies have used CPM to examine family communication about NMOU. Similar to previous studies using CPM, NMOU is a stigmatized situation about which individuals are likely to feel vulnerable disclosing, potentially prompting important risk-benefit analyses about disclosure.

Having a loved one with NMOU places tremendous strain on the individual and the family system (Crowley & Miller, 2020), potentially increasing the desire to reach out for emotional, and informational support. In fact, research suggests that social support is vital to the buffering of stress on the individual’s mental and physical health in general (Cohen & Wills, 1985) and specific to substance use disorders (Brown et al., 2015). At the same time, NMOU is highly stigmatized, and stigmatizing behaviors among family members are often the most rigidly concealed. Therefore, how family members with a loved one with NMOU communicatively navigate this dialectic tension between revealing and concealing stigmatized and stigmatizing information becomes an important object of study, and potentially informs interventions for families of individuals with NMOU.

Current study

Informed by FST and CPM theory, the purpose of this study was to understand more deeply how families communicate about their loved one’s NMOU. The following research questions guided this inquiry:

RQ1

How do AFMs communicate about their loved one’s NMOU to others within their immediate family system, including the individual with NMOU

RQ2

How do AFMs communicate about their loved one’s NMOU with individuals outside of the immediate family;

RQ3

How do CPM strategies impact AFMs’ interpersonal relationships within and external to the family system?

Method

Sample

We conducted interviews with 34 Michigan residents 18 years of age or older who identified as an immediate relative of a person with a history of NMOU. The sample was primarily cisgender female (70.6%, n = 24), followed by cisgender male (29.4%, n = 10). Most participants were white (76.5%, n = 26), with the remaining participants identifying as Black or African American (8.8%, n = 3), Asian (5.9%, n = 2), Middle Eastern, (2.9%, n = 1), Puerto Rican (2.9%, n = 1), or Native American (2.9%, n = 1). Participants ranged from 20 to 74 years (M = 47.9, SD = 16.6, Mdn = 49). AFMs were parents (n = 13), children (n = 11), siblings (n = 11), and/or spouses (n = 1) of loved ones with histories of NMOU. The majority (76.5%, n = 26) talked about a family member with past NMOU who was at the time of the study in recovery (44.1%, n = 15) or deceased (35.3%, n = 12). Eight participants (23.5%) talked about a family members’ current NMOU. Three AFMs talked about multiple family members.

Data collection

In-depth, one-on-one interviews were conducted via phone by five research team members, some of whom are in recovery and/or are AFMs. Our roles as people in recovery and/or AFMs likely impacted how we talked with our participants and how we interpreted our data. For example, the questions we asked and the themes we identified in the data may have resonated with our own personal experiences. However, we see these life experiences related to substance use disorders as an opportunity for reflexivity rather than a hindrance (Carolan, 2003), as our experiences situated us well to build rapport with AFMs and be sensitive to their experiences. We also met frequently throughout data collection and analysis to reflect on our findings and process our personal reactions in order to minimize potential bias. All interviewers were trained in interview procedures, debriefing, and qualitative interviewing practices prior to conducting any interviews. Participants received a $25 Amazon e-gift card via email and debriefing materials with information about how to access support services for people impacted by NMOU following their interview.

The interview guide was developed by a subset of our research team across several meetings. The finalized interview guide had 18 primary questions, each with prompts. Questions relevant to this manuscript prompted participants to discuss how their family talks about their loved one’s NMOU with each other and people outside of the family. However, the semi-structured approach left room for “new and unexpected” phenomena to arise (Brinkman & Kvale, 2015, p. 33).

Upon approval from the Wayne State University institutional review board, we recruited AFMs from a pool of participants that took part in a previous study (Pasman, et al., 2023). In the original study, AFMs were recruited through publicly funded treatment providers, support groups for family members, and our university’s social media platform. These participants were required to be residents of Michigan and identify as having a close family member (defined as parent or stepparent, child or stepchild, spouse, sibling or half/stepsibling) who experienced problems with opioid use. An email script describing the current study was sent to participants that had opted in to being contacted for future research opportunities.

Interviews averaged approximately 48 minutes (M = 47.45, SD = 18.66) and ranged from 15 minutes to 1 hour and 36 minutes in length. Audio recordings of interviews were professionally transcribed, resulting in 556 pages of single-spaced text. Transcript accuracy was verified by members of the research team. Interviews were conducted until saturation was achieved, defined as when no new ideas or information pertaining to our research questions arose (Tracy, 2019). Saturation was achieved at interview 30. We conducted four additional interviews to ensure no new phenomena relevant to our research problem were emerging.

Data analysis

We used Dedoose qualitative coding software and Tracy’s (2019) iterative approach to guide our data analysis. The iterative process allows the researcher to reflect on emergent findings, as well as existing theoretical frames and models (Tracy, 2019). Following this approach, three research team members engaged in data immersion, primary-cycle coding, second-level coding, and codebook construction and revision, meeting regularly to reflect on the findings (Tracy, 2019). During data immersion, the coders met twice to discuss what was standing out to them in the data and brainstorm a code list. Initial concepts that emerged included conflict with family members, conflict with loved ones, open and closed communication, etc. After data immersion, we began open coding the data during the primary cycle coding phase. Team members made analytic memos as they analyzed data. Constructs related to dialectical tensions emerged as relevant existing concepts as we progressed through data analysis but were not used to deductively code our data. We met five additional times throughout primary- and secondary-cycle coding to draft and refine our codebook and reflect on what we were learning from our data. For example, our findings were organized around the constructs of dialectical tensions as we worked through secondary coding and drafting a loose analysis outline. Each transcript was initially coded by one team member and subsequently reviewed by the second two team members.

Findings

Patterns of communication with immediate family members, including the loved one with NMOU, and with those outside the family system reflected the dialectical tension of both wanting to share information to be known and supported, while also wanting to conceal or actively concealing information to avoid stigma or negative relational consequences. AFMs appeared to walk a fine line between rigid (closed) and permeable (open) communication boundaries. Responses suggest that the CPM process was an active process that required deliberation, discussion with trusted others, and movement or change over time. Privacy management often required traversing a series of communication dialectics that were difficult to maneuver, and risk-benefit analyses of potential disclosure that shifted over time.

CPM dialectical tensions both within and outside the family system included Open versus Closed communication, Frequent versus Infrequent communication, and Desire to be Open versus Need to Withhold. Risk-benefit analyses of potential disclosure were identified as participants described weighing their Need for Information about NMOU against their Fears of Being Judged. The nature of confidants external to the family was also discussed as disclosure was facilitated by Supportive confidants who Shared Similar Experiences and not by Unsupportive confidants who Didn’t Understand. Some participants appeared to have made peace with communication dialectical tensions by identifying what we have called Resolutions to the communication dialectical tension such as providing Functional Updates, Focusing on the Good, movement over time from Closed to Open communication, and Shifting Perspective about NMOU. These Resolutions seemed to improve coping and interpersonal relationships within and outside the family system. CPM strategies had a range of effects on interpersonal relationships within and external to the family including, creating Stronger or Weaker Relational Bonds, and allowing for Relational Repair.

Communication privacy management strategies within the family system

Open versus closed

When discussing how they communicated with others in their family about their loved one’s NMOU, AFMs described the dialectical tension between having Open versus Closed communication boundaries. Open boundaries were characterized by the free sharing of information with others in the family about NMOU or about the individual with NMOU, and the honest and direct flow of information. One participant said, “Within my immediate family we talked about it a lot” (Participant [P] 33), while a parent of a daughter with NMOU explained, “My husband and I talked about it – I mean, we talked with our younger daughter” (P9). One mother talked about the importance of being open with her children about their genetic vulnerability to addiction stating, “I told my kids. I said, ‘you know your genes are not the best when it comes to addictive behaviors. So, keep that in mind as you go through life’,” (P13).

AFMs also described communication boundaries that were to some degree Closed when talking with others in the family about NMOU or the individual with NMOU. This was characterized by a purposefulness in withholding information and an unwillingness to talk directly about specific topics related to the opioid use disorder. For example, one participant whose mother had engaged in NMOU stated, “My brother and I never really talked about it. And I don’t know if my other family members knew, or if they knew and they just didn’t want to say anything. Because it was never talked about,” (P5). Similarly, another participant stated, “We didn’t really talk about it. And to be honest, we still don’t,” (P26).

AFMs also described Open communication boundaries in their communication with the loved one about their NMOU, where information was shared and discussed and characterized by honesty and directness. One father described his communication with his daughter with NMOU as open, “I pulled into the parking lot there and turned off the car and said, ‘Well, [name redacted], what’s the issue? What are you struggling with?’ And she said, ‘The worst dad. The worst.’ Oh God my heart fell. [My] stomach fell,” (P6). A mother described her communication with her son who used opioids this way, “We had a good talking and communicating relationship even as he was using. It was important to me since they were babies. Communication was open and he knew that we loved him and would help him,” (P18).

AFMs also described communication boundaries that were to some degree Closed with the individual with NMOU. This type of communication was characterized by an inability or unwillingness to talk directly about specific topics (usually related to the NMOU), avoidance of direct communication, and in extreme cases, avoidance of any communication with the individual with NMOU. For example, a mother whose son struggled with NMOU discussed her husband’s closed communication stating, “My husband was not talking to anybody, even me, his family, nothing. He was just some vinyl log,” (P10). One adult child of a parent who struggled with NMOU stated about their mom, “We didn’t really talk about it. I remember one time watching Doctor Phil or some talk show. There was a mother and son on it, and one was addicted to Vicodin, and my mom was mad about that,” (P5).

Frequent versus infrequent

Participants described frequent communication within the family about the NMOU and about the individual with NMOU. One participant talked about their sister and stated, “Within the immediate family we talked about it a lot because again, we wanted to make sure that she got the proper help” (P33), while another participant stated, “We talk about it a lot, all the time” (P17). Another participant, a parent who lost their son to NMOU, expressed concerns about talking about the NMOU too frequently stating, “We talked [about the NMOU] too much… It ruled our life, and it shouldn’t have” (P14).

Participants also reported very infrequent communication within the family about NMOU. One child of a parent with NMOU stated about her family, “We didn’t really talk about it, and….we still don’t” (P26) while another stated “Not to my youngest. No, not a whole lot. She was also too little to understand” (P11). Another participant, a parent of a child with NMOU, stated, "His brother and sister don’t talk about him at all anymore” (P17).

Wish to be open versus need to withhold

Some participants expressed a wish that they had been more open or desire to be more open about NMOU with other members of their family. One child of a parent with NMOU stated, “I wish I would have had somebody who knew what was going on. And I wish I had somebody to talk to about it” (P5), while another participant stated, “I want to be more open about it because we have family members going though it that need help” (P28). Other participants described purposely withholding information about NMOU from other family members. For example, the prior spouse of a person with NMOU described withholding to protect his other children, “I like to call it the dirty little secret. So, I really protected and shielded my kids from it” (P20), while another stated, “I didn’t share information with others in the family, just so they wouldn’t be knowing what was going on” (P23).

Nature of confidants

Supportive versus unsupportive/strained

The nature of confidants and their responses to disclosure seemed to range from Supportive to Unsupportive or Strained. Descriptions of supportive responses from confidants within the family included general support offered and support specific to treatment for the individual with NMOU. One woman whose sister died from complications associated with NMOU described support from her husband,

He’s been very supportive. He listens to me talk [about my sister] all the time. We’ve talked a lot to each other about it and, obviously he was there when my sister passed away and...so, he’s been really supportive and he’s really open to talking about it with me (P28).

One woman whose mother had NMOU described supportive communication regarding treatment with her sister, “We want the best for our mom but it’s a lot to mentally deal with. So, we would be able to vent to each other and talk about the logistics of the substance abuse” (P22).

Descriptions of Unsupportive or Strained responses from confidants within the family system abounded, especially as attempts to discuss the NMOU were met with general dismissiveness or a combination of anger, conflict, and blame. Strained communication included generally unsupportive types of communication and strained communication due to conflict. One participant who had a sibling with NMOU described general unsupportiveness when she said, “I guess the closest person was my dad. We tried talking to him about it, but him and my mom were in their divorce, and they were so focused on themselves and each other” (P8). Another participant, the child of a parent with NMOU, described conflictual unsupportiveness stating,

We don’t talk about anything like that. Anytime I brought it [NMOU] up it ended in a big fight. I pretty much dealt with it alone, her [daughter] and me alone. Nobody but me participated in her care in rehab even. I was the only one who saw it all (P15).

Communication privacy management strategies external to family system

As described earlier, CPM strategies help individuals balance the need to limit communication to prevent information sharing, and the need to disclose information in order to facilitate support and relationships. Strategies that limit information sharing protect the individual from conflict and from the potentially negative social consequences of stigma but have the unintended consequence of increasing social isolation and absence of support. Strategies that increase information sharing potentially engage social support with the unintended consequence of vulnerability to judgment and conflict. Similar privacy management strategies were used with individuals external to the immediate family system as those used within the family system, including Open versus Closed, Frequent versus Infrequent, and the Desire to be Open versus Need to Withhold, as well as the need for confidants to be Supportive rather than Unsupportive/Strained. However, risks and benefits were considered in relation to disclosures external to the family system as AFMs weighed their need to Seek Information about NMOU against their Fear of Judgement. An additional quality of confidants also emerged as AFMs described disclosure being facilitated by confidants with Shared Experiences rather than those who Lacked Understanding.

Open versus closed

Similar to descriptions of communication within the family, AFMs again described both Open and more Closed boundaries in their communication about the loved one or the loved one’s NMOU when communicating with others outside the immediate family system. Open communication was characterized by the free sharing of information with others outside the family about the NMOU or about the individual with NMOU, and the honest and direct flow of information as reflected when one participant stated, “Yeah, everybody knows….and if anything, they tell me ‘Gosh we really respect you for being so supportive of your daughter’,” (P6). AFMs also described communication boundaries that were to some degree Closed when talking with others outside the family about the NMOU or the individual with NMOU. Closed boundaries were characterized by a purposefulness in withholding information and an unwillingness to talk directly about specific topics related to NMOU. For example, one father whose son struggled with NMOU stated, “How do you even start the conversation? ‘How’s your son doing?’ ‘Oh, he’s fine.’ You don’t delve into the question…. They don’t come out and say, ‘how’s your son and his substance use disorder? How is that going?’ You don’t share that” (P13).

Frequent versus infrequent

Similar to CPM strategies used within the family system, AFMs utilized both frequent and infrequent communication with individuals external to the family system. One woman reported that she frequently, “talked more about it with people on the outside [of her family]” (P13), while another AFM stated, “I have some very good friends, and I talked to them about my son all the time” (P17). Reflecting the opposing end of the dialectic, infrequent communication, one AFM explained, “Outside the family, say if it would have been at work or school or something I didn’t really talk about it” (P25).

Desire to be open versus need to withhold

Similar to CPM strategies used within the family system, AFMs described their desire to be open in order to garner support from others, while also feeling a need to withhold information from others to manage the turbulence and the secrecy of the loved one’s NMOU. One woman whose mother had struggled with NMOU during her childhood expressed her desire to have experienced more openness as a child, “I wish that there was someone trained in my school to work with kids and families to destigmatize the notion that a family member has addiction. I’m sure there were tons of kids in my school going through this” (P19). Another AFM explained withholding this way, “You don’t talk about it because you’re embarrassed. You don’t want them to dislike your kid” (P11).

Nature of confidants

Supportive versus unsupportive/strained

AFMs described both supportive and unsupportive or strained responses from confidants external to the family system. Some AFMs described the reciprocal process of communicating support external to the family system. One adult son of a mother with NMOU stated, “One friend of mine would ask, ‘Hey man, how’s your mother doing?’ I thought that was really nice. That’s really all the support I would want,” (P22) while another AFM described the satisfaction associated with offering support to others, “You know, other parents talk to me. This other mom who lost her son, I started helping her...and she thanks me all the time” (P10). Another AFM whose mother had NMOU described unsupportive responses from people outside her family in that, “They just don’t want to talk about anything… They didn’t know what to do so chose to do nothing,” (P22). Unsupportive responses were strained at times as one woman said, “She would just completely dismiss me as if I was lying about what was happening,” (P8).

Shared experiences versus lack of understanding

AFMs described both having shared experiences when communicating about NMOU with people outside the family, and, conversely, discovering that people outside of their family did not understand their experience. One adult son of a woman with NMOU discussed a lack of understanding among people in his network, stating,

When she would be under the influence and people would see [her that way], I would just say that she was really tired. I would just basically lie. I didn’t want to see her suffer [judgment], especially from people who didn’t understand, (P15).

Another AFM, discussing a woman he had dated, explained,

She was one of those people, let’s say, for whom nothing disastrous with her kids had ever happened. So, she was pretty ignorant of the real world. She opened her mouth and said the wrong thing [about NMOU] and it was very hurtful, (P18).

Although AFMs described others’ lack of understanding of their experience as hurtful, they also described experiences of open communication about NMOU being met with reciprocal disclosures and a sense of shared experience with people outside the family. Often, but not always, these experiences occurred in peer support groups and meetings. One AFM, a member of a state-wide family support program described,

I was on the substance use disorder task force [at work], and my daughter and I were asked to share our story [at a work event]. We shared in a small group which was helpful. It was cool to share the lived experience and to influence others, (P9).

Another AFM was struck by the responses they received once they started to share their experience outside the family, reporting, “You know, you start talking about it [your experience as an AFM] to people, and they know someone [with NMOU]. It becomes a discussion because pretty much most people have some kind of experience in this area,” (P18).

Risk-benefit analysis

Seeking information versus fearing judgement

AFMs discussed the risks and benefits of disclosing to others outside the family system as a struggle between their need to seek information about NMOU and about effective treatments, and their fear that this openness could leave them vulnerable to being judged by others for having a family member with NMOU. One AFM described the importance of reaching out for information this way:

I think there’s a lot of medical information out there [about NMOU]. There are a lot of opportunities to reach out [for information], but you got to reach out yourself. Whether you’re the parent [or] the spouse, you got to be reaching out, (P18).

One AFM, a father whose son abused opioids, described seeking information through a peer support group stating, “This is a perfect example in terms of getting information. We became members of a group called [statewide peer support group]. We learned more about Naloxone and how it works that way,” (P21).

AFMs also described fears of being judged by others for NMOU if they disclosed their experiences as an AFM to seek information. One man described his inability to get help or information as a youth dealing with his parent’s NMOU: “If there had been no stigma attached when I was young, I might have said something sooner. And somebody might have been able to tell me about services. There never even was, at least for me, that option,” (P23). Another AFM discussed her process of discernment in identifying those from whom she might receive support and information versus those from whom she would endure judgement stating, “The people in our lives, not our support system, but maybe some of the church people or her siblings, for the most part, were pretty judgmental [about NMOU],” (P15).

Resolutions to communication dialectical tension within and external to the family system

Focus on the good

Participants described attempts to remain focused on the positive aspects of their loved one with NMOU. One mother explained, “We mostly just talk about his improvement. We don’t really dwell on how it used to be,” (P26) while a father stated, “Our immediate family. We talk about the good times,” (P2). Communicating with other family members about the positive qualities of the individual with NMOU seemed to have a positive impact on relationships and coping. One mother reported that her son was

my middle child...the easiest pregnancy, [and] easiest kid to raise. He was compliant and sweet and perfect....and even when struggling with addiction he tried to please and do his best. He never stole from us. Sometimes he would get abusive, but it was always when he was on an opioid or an amphetamine, (P7).

Functional updates

Focusing on communicating functional or concrete information to others about the NMOU or the loved one with NMOU was one resolution AFMs employed to balance the tension between closed versus open communication boundaries. In describing his role with his mother with NMOU, one man stated, “I mainly let my brother know what he can and can’t do around her, especially if she’s in a bad mood. Like, try not being too loud. Try to phrase stuff in a non-aggressive way” (P29), while another reported communicating “just to keep tabs on [their loved one with NMOU],” (P1). Another participant, a woman whose mother used opioids described communication with her sister as, “about logistics. We got to do this. We got to call the doctor. We got to pay her bills. That kind of stuff,” (P22).

Moving from closed to open communication

AFMs described an organic and constantly changing process of communication boundary management by which they moved from more rigid boundaries and more closed communication to more flexible and open communication boundaries in which more information was shared between family members and those outside the family more openly. Over time, participants’ views of NMOU shifted; they experienced less stigma and were more willing to risk judgment to receive interpersonal support. One participant eloquently described a shift over time from closed communication boundaries to open communication boundaries:

Eventually you stop making excuses, and you start just being open about it. I talked about it at work, [and] found out one of my coworkers her son had died from an overdose on his 21^st birthday. Another coworker was going through the same thing with me, and we started talking every day. Eventually you do share with family and friends. You have to, eventually. (P11)

Shifting perspective

Movement from closed to open communication appeared to be facilitated by shifts in AFMs’ understanding of NMOU. As their understanding shifted, stigma reduced, and AFMs moved toward more open communication about NMOU both within and external to the family. One participant stated:

People have ideas about what somebody with [an] addiction looks like or is, and it’s really not the case. Like, me. So many people would be shocked to know that so many people... that we wouldn’t assume would have an addiction, have it, that anyone can struggle with it [NMOU] and it doesn’t really choose fairly, (P15).

Another participant put it succinctly when he said, “seeing it first-hand made me realize it is an illness and not something that they want for themselves,” (P26).

Impact of CPM strategies on relationships over time

CPM strategies used by AFMs when communicating about NMOU with their family or with people outside the family had an impact on AFMs and on their relationships within and external to the family over time. Themes that emerged and described the impact of strategies on self and relationships included, Stronger or Weaker Relational Bonds, and Relational Repair.

Stronger/weaker relational bonds

AFMs described eventual improvements in their relationships both within and external to their families. Open communication and sharing the hardships related to having a family member with NMOU appeared to have led to stronger, more connected relationships. One AFM reported, “I have been able to maintain a very healthy relationship with all three of my immediate family members,” (P22). A woman whose mother had struggled with NMOU stated, “If anything, it probably made my brothers and I closer. We definitely had to do some of these battles together because I needed help,” (P15). A man whose sister had NMOU described changes in his relationship with his parents: “When I educated my parents, I told them, ‘hey, my sister might be abusing this drug.’ It definitely brought my family and I closer together because we wanted to be sure she got the proper help,” (P33). Another AFM described open communication with those external to her family: “I learned the more I talked openly about this the more I found other people going through the same thing I ended up with people I worked with becoming close,” (P2).

AFMs also described how their relationships within and external to the immediate family became weaker and less connected due to NMOU and CPM strategies. Of her family one woman stated, “It [NMOU] had a big impact on my family. It was a strong factor into a divorce in the family,” (P22). One woman, referring to closed CPM strategies and relationships external to the family said, “I never had that big of a group of social contacts, but I just stayed away from people for so long that it’s like they would think we drifted apart,” (P4). In discussing relationships and closed communication one woman explained, “My brother was always very closed mouth, and I think the way he turned out is a result of my mother’s substance abuse,” (P5).

Relational repair/healing

Participants also described relational repairs and healing that occurred over time with other family members and with the loved one with NMOU. These relational reparations were associated with a decrease in unsupportive/strained communication. One man described Relational Repair with his wife this way, “Our relationship went bad but then we started to get help for ourselves through support groups and our relationship is much better now,” (P2). This man also described the relational benefits of seeking help and information:

My wife and I talked about it a lot. We were both arguing about it. After we sought recovery for ourselves, we were able to sit down and discuss what we thought the next steps should be. We were both in agreement about what to do,” (P2).

One father explained, “As my daughter recovered there was a full circle where she and her sister have reconnected in their relationship.” (P9).

Discussion

Petronio and Caughlin (2005) established that when families have a member struggling with a stigmatized illness or identity, they must actively work to identify whether and how to reveal information related to that stigmatized illness with others or withhold that information, requiring the use of CPM strategies. Findings from the current study affirm that CPM strategies are used by AFMs of individuals with NMOU when communicating both within and outside of the family system; this is an active ongoing process whereby AFMs attempt to traverse the opposing needs to both disclose to others and maintain the privacy of a stigmatized illness.

AFMs experienced complex dialectical tensions in communication, reflected in the themes of closed versus open communication, frequent versus infrequent contact with others, and the desire to be open versus need to withhold. AFMs also engaged in risk-benefit analyses by weighing the potential risks of being judged against their need for information about NMOU. Qualities of confidants also affected participants' motivation to share or not share information as having supportive confidants who shared similar experiences facilitated participants’ decisions to disclose about NMOU. These findings support Petronio’s (2002) previous work on privacy management within families, while also providing new information on the qualitative experience of these tensions as they manifest specifically for AFMs of individuals with NMOU.

Novel findings from this study illuminate some of the strategies that AFMs organically developed and utilized to manage or resolve dialectical tensions. Resolutions to dialectical tensions included boundary setting, focusing on the good, functional updates, moving from closed to open and shifting perspective. These resolutions were central to managing the dialectical tension between the risk associated with disclosure of NMOU such as judgement and stigma, and the potential benefits of disclosure such as interpersonal support and information about NMOU and treatment for NMOU. While boundary management is central to the work of Petronio and Caughlin (2005) and therefore not a novel finding, AFMs decision to limit their communication to functional updates were specific to this population and not previously described in the literature. Further, AFMs’ decision to focus on the good when communicating about the individual with NMOU has been described in extant literature as a strategy for managing stigma related to substance use (Meisenbach, 2010; O’Shay et al., 2023; O’Shay-Wallace, 2020). As such, managing stigma may be a key process related to privacy management. These represent new areas of communication privacy management, the ways that AFMs organically discover methods for managing communication tensions inherent to having a loved one with NMOU.

The changeability of privacy choices was evident in the findings that AFMs often moved from Closed to more Open communication over time. As Petronio and Caughlin (2005) explained, once disclosure of stigmatizing information occurs the communication boundary expands from an individual or family to a group boundary and information becomes collectively held within the group. This process was described by AFMs for whom communication moved from Closed to Open, as information was shared with new people within and outside the family. However, findings from this study support that movement from Closed to Open is related to Shifting Perspective; As AFMs’ perspectives on NMOU shifted from more to less stigmatizing they communicated more openly, and greater openness provided opportunities for information to be held by a larger community, thereby decreasing stigma. This finding builds on existing research that suggests AFMs’ communication about stigmatizing attributes changes as their perception of the stigma changes (Brule & Eckstein, 2016; Meisenbach, 2010; O’Shay et al., 2023; O’Shay-Wallace, 2020) and adds to our understanding of the nuances involved in a family’s shifting privacy choices.

Afifi (2003) has highlighted the importance of coordinating privacy boundaries within the family, and the resultant turbulence that may ensue when there is no agreement among family members as individuals move from closed to open communication. While some AFMs did briefly allude to within family disagreement about closed versus open communication, AFMs generally expanded on the benefits of open communication to relationships both within and external to the family system over time. Communication characterized by greater openness and willingness to risk disclosure appeared to be related to Stronger Bonds with others and Relational Repair between the AFM and other individuals within and external to the family system, as well as their relationship with the individual with NMOU. This is an important finding as models of coping with a loved one’s NMOU identify interpersonal support as a central component of coping for AFMs (Orford et al., 2010). This finding adds to the literature as potential interpersonal benefits of moving from closed to open that may be as important to consider as the potential for negative consequences such as turbulence.

When considering stigmatized identities such as individuals with NMOU, communication boundaries and CPM strategies are consistently shifting based on the family’s and the individual’s interaction with the world external to the family system. As AFMs gained newer understandings of addiction and greater information about NMOU from individuals and systems external to the family, their perspectives about NMOU shifted from a stigmatizing perspective that isolated them from others to a greater sense of the universality of the problem. CPM strategies changed in conjunction with the shift in perspective from secrecy-supporting strategies to greater openness. While CPM strategies focus on the impact of family members on one another, it is important to remember that the world also impinges on the family, potentially affecting which CPM strategies are used when, and the intensity of the communication dialectical tensions experienced. Additionally, the CPM strategies used, and the qualitative experience of dialectical tensions may be specific to certain issues, such as NMOU, populations such as AFMs, and communities. This study expanded our understanding of the privacy management strategies, dialectical tensions, resolutions of dialectical tensions, and impact on relationships for AFMs of individuals with NMOU.

Implications for practice and research

There is much more to be known about the impact of the world on the family system’s use of CPM strategies. It is important to understand how family communication and privacy management impact the well-being of individual family members and the family unit. Future research should examine the impact of contextual forces such as culture and community on CPM strategies among more diverse families. Additionally, future research might focus more on the reciprocal nature of CPM strategies in relation to community and world. While more open communication created larger social networks or groups of individuals who held information about NMOU, the experience of community and sharing issues related to NMOU with others outside family also seemed to impact the use of CPM strategies and the dialectical tensions related to communication.

While courtesy stigma related to NMOU may be a significant factor in individuals’ decisions not to disclose, and the desire for support may provide motivation in favor of disclosure, findings suggest additional motivations for disclosing or not disclosing. Participants identified fear of judgement and fears of not being understood or supported in response to disclosure as motivations for non-disclosure. Additionally, feeling supported, understood and in need of information about NMOU, were motivations for disclosing information about NMOU to others. While these findings add to our understanding of motivations for disclosure/non-disclosure among AFMs this topic was underdeveloped in this study. According to CPM people feel less vulnerable when more in control of personal information. Given that having a loved one with NMOU can feel so out of control it is possible that decisions to not disclose may be motivated by attempts to experience or regain a sense of control. Other risks to disclosure of private information might include fears of relationship deterioration, loss of face, and emotional hurt (Petronio, 2002). Future research might specifically examine in more depth motivations that determined decisions to disclose or not disclose about NMOU among AFMs.

Interventions with individuals with NMOU should maintain a family systems approach and assist families to identify how patterns of communication influence relationships and in some cases recovery (Crowley & Miller, 2020). Since different families and different individuals within families have distinct communicative responses to NMOU, intervention approaches should be individualized to meet the needs of the family unit and individual family members. For example, based on Afifi’s (2003) recommendation that families should discuss how to manage privacy around family matters, practitioners, such as social workers, therapists, and healthcare providers, should work with AFMs to develop strategies for talking with their family members about privacy expectations surrounding NMOU. In line with our findings, these strategies should advise families on how to set expectations for privacy, as well as negotiate conflict and changes related to these expectations as individual AFMs may find themselves wanting to become more open about their experience over time. How families communicate and cope with NMOU is further complicated by influences outside the family system, such as stigma, which can further impinge on communication patterns (Crowley & Miller, 2020). Thus, macro-level interventions that decrease stigma are also important, as decreasing stigma may serve to lessen the dialectical tension between the need to maintain privacy and the need to disclose information in order to develop social support resources.

Strengths and limitations

There are several strengths and limitations to consider when interpreting findings from this study. First, our sample was primarily comprised of white individuals (76.5%) and individuals that identify as women (70.6%). Race, ethnicity, and gender may have implications for how families communicate about a loved one’s NMOU, and sample homogeneity may limit the representations of a diverse range of families’ experiences. Second, most participants identified as either a parent or child of an individual with NMOU. AFMs with other relationships to individuals with NMOU may describe their family communication about NMOU in diverse ways. Third, because we did not consistently collect the amount of time that participants had been affected by a family members’ NMOU, our ability to draw connections between the duration of NMOU and family communication patterns was limited. Additionally, approximately one-third (32.4%) of the study sample included people that participated in a statewide support group for AFMs. It is possible that AFMs who engage in support groups differ in how they communicate about their loved one’s NMOU. Finally, we did not ask participants about their disability status, sexual orientation, or socioeconomic status and therefore offer no implications regarding this. These study limitations offer opportunities for future research to investigate how families communicate about a loved one’s NMOU from a diverse range of perspectives. Despite these limitations, this study furthers our understanding of family communication about NMOU, including how AFMs communicatively manage privacy around their loved one’s NMOU, for which they may anticipate or experience stigmatization by others.