The elephant in the room: Metaphors in women's accounts of life with a family member with problematic substance use

Abstract

Background: Research has shown that a family member's problematic substance use has significant deleterious mental and physical health impacts on other members of the family. Women are more often affected than men. These negative health effects persist as the person with problematic substance use ages, and they vary according to the relationship status. Aim: The aim of this study was to gain a deeper understanding of how women experience and are affected by their family member's substance use problems. Method: A metaphorical analysis of narrative interviews with 11 daughters and five wives of older adults (>65 years) with problematic substance use. Results: We identified four areas of signification in which metaphors were employed: (1) experiences (chaos and crash and walking on eggshells); (2) strategies (complicity and silencing); (3) dilemmas (deceit or a disease and open or closed dilemmas); and (4) consequences (obtaining or retaining an identity, health and different types of help). Conclusion: Family life with a parent or spouse with a substance use problem was described as chaotic, unsafe, uncertain and with no prospects of change. The study illustrates how metaphors are used to mediate experiences and worldviews pertaining to existential matters founded in deep negative emotions, deceit, shame and stigma. Metaphors make up a crucial material for communicating emotions and themes that are difficult to convey due to shame and stigma.

Substance use in most Western countries, including Norway, has increased in the past decades. This applies to both problematic alcohol and psychotropic drug use among older age groups (>65 years) (Bratberg et al., 2016; Kelfve et al., 2014; Rao et al., 2015; Stelander et al., 2021; Tevik et al., 2017, 2019).

Problematic substance use among older adults in the family is associated with significant negative health impacts on their family members (Orford et al., 2013; Rao et al., 2015). A recent scoping review pointed out that for decades, these family members have been implicated in the pathology of substance use, but their needs still remain to be recognised in the services (Di Sarno et al., 2021). The study by Di Sarno and colleagues (2021) also underlines that stigma, self-blame and social isolation are common among close relatives of older adults with problematic substance use.

Furthermore, studies have shown that children living in families where adults have substance use problems experience a range of negative outcomes (Nordlie, 2003), including post-traumatic stress disorder (Alisic et al., 2014), interrupted sleep patterns, and physical and mental exhaustion (Kristiansen & Myhra, 2012). Family members living apart from an adult relative with problematic substance use may similarly experience negative outcomes (Newton et al., 2016).

A small quantitative study recently found that problematic substance use among adults was associated with significant negative consequences for the families and, particularly, for female family members (Hellum et al., 2021). Further risk factors for negative health outcomes among female family members reported in this study were lower socioeconomic status and cohabiting with an adult with problematic alcohol use. In addition, a Norwegian report has found that most family members referred to specialist treatment services due to a relative's problematic substance use are female (Kristiansen & Myhra, 2012). Typically, these women had lived with their partner's alcohol or substance misuse for several years. Approximately two-thirds reported seeking help only after living with alcohol misuse over time and after a specific critical incident (Kristiansen & Myhra, 2012). Lindeman et al. (2022) suggest the delay in seeking help may stem from the family members’ experiences of shame, guilt, exhaustion, grief and perceived lack of support (Birkeland, 2019; Lindeman et al., 2022; McCann & Lubman, 2018a, 2018b; O'Shay-Wallace, 2019).

The consequences are likely to persist as the family member with problematic substance use grows older. Research indicates that girls and women are likely to be disproportionately affected by associated negative health outcomes and impaired quality of life (Alisic et al., 2014; Kristiansen & Myhra, 2012; Newton et al., 2016), but few studies have examined how female relatives, such as daughters and wives, are affected by their ageing relative with problematic substance use. Knowledge of female family members’ lived experiences is nevertheless fundamental to developing targeted health services and interventions (Duckert et al., 2008; Johannessen et al., 2015, 2021a, 2021b; Kjosavik, 2012).

Our study therefore covers daughters’ and wives’ experiences of their older family member's problematic substance use. We inquire into the meaning and relevance of the metaphors that they mediate. Our aim was to gain an understanding of how these female family members experience and are affected by substance use problems.

Metaphors

A metaphor is a construction that mediates an experience or situation by describing it in the imagery of another experience or situation (Ricoeur, 2003). Metaphors are “verbal pictures” (Federel & Eftedal, 2018), and according to Lakoff and Johnson (1980), they are common to the extent that we do not pay attention to them. As such, metaphors play a central role in defining and describing our everyday experiences and emotions. Lakoff and Johnson (1980) propose the following typology of metaphors: structural, orientational, ontological and new metaphors. Structural and orientational metaphors are basic ways of structuring the world around us and include directions, sizes and speeds. They are based on simple physical concepts; up and down and in and out are basic in our conceptual system, unlike “They are not in themselves very rich” (Lakoff & Johnson, 1980, p. 61). They are common, cultural and conventional examples of verbal expressions. Ontological metaphors are used to make sense of particular events, activities, emotions and ideas (Lakoff & Johnson, 1980). They indicate the individuals’ identity and their ways of making meaning of experiences and events. In this study, we are interested in the interviewees’ experience of their life with a family member that has long-lasting substance use problems. The participants’ use of ontological metaphors gives access to their feelings and experiences of everyday life with a close family member who has substance use problems.

Metaphors are not only the interest of linguists or literature and communication scholars, but social scientists, too, have come to pay increasing attention to the potential they have for communicating life experience and unique perspectives. Increasingly, metaphors have, for example, become tools in healthcare interventions (Tay, 2016). Because therapists and clients often struggle to find words to convey emotions, it is “difficult to describe sensations, emotions, psychological states, and views of the self” (McMullen, 1996). A contextual turn and promising trend in the study of metaphors is a recent focus on how they function in various therapeutic work contexts and circumstances. Metaphors may, for example, enable family members to allude to sensitive and shameful feelings and experiences indirectly (Tay, 2016), presenting opportunities to address sensitive topics, generate emotional distance from a difficult subject matter or provide therapeutic tools for overcoming challenges. As such, metaphors may offer health professionals a variety of therapeutic points of entry into affected family members’ experiences and support needs. This is increasingly recognised as an asset in health communication research.

Methods

Material

We interviewed 16 female relatives (wives and daughters) of older Norwegians with problematic alcohol use, some of whom also had problematic potential psychotropic drug use (Johannessen et al., 2022).

Health personnel at two hospitals and three voluntary organisations in Mid- and Southern Norway recruited the participants by telephone. Of the 16 participants, 11 were daughters and five were wives/cohabitants of an older adult with problematic substance use. In the text hereafter, we refer to wife/cohabitant as “wife”. The 11 daughters were aged 31–57 years and the five wives were aged 53–66 years. The interviewees’ parents or partners were aged 62–85 years of age at the time of the interviews. All participants had lived with the relative for an extended period. Additional participant characteristics are listed in Table 1.

Table 1.

Overview of the characteristics of the wives, daughters and the older family member with a problematic substance use.

Wives and daughters					Family member with a problematic substance use
Participant number	Relation (age)	Age when misuse started	Civil status	Own children	Relation (age)	Civil status	Type of misuse
1	Daughter (47)	6	Married	2	Mother (77)	Divorced	Alcohol and drugsa
2	Daughter (32)	4–5	Single	0	Father/Mother (74/73)	Divorced	Alcohol and drugsa,b
3	Wife (53)	Always	Married	2	Husband (62)	Married	Alcohol and drugsa
4	Wife (59)	Always, but escalated over past 25 years	Married	1	Husband (62)	Married	Alcohol
5	Daughter (49)	8	Single	0	Father (85)	Married with the mother	Alcohol
6	Daughter (36)	5–6	Married	2	Father (70)	Married with the mother	Alcohol
7	Daughter (57)	Early childhood	Married	1	Father/motherc (deceased/80)	Divorced	Alcohol
8	Daughter (31)	Teenager	Single	1	Mother (63)	Married with the father	Alcohol and drugsa
9	Daughter (40)	6–7	Divorced	2	Mother (65)	Cohabitant (divorced from the father)	Alcohol and drugsa
10	Daughter (43)	6–7	Single	0	Father/mother (65/66)	Divorced	Alcohol
11	Daughter (31)	12	Single	1	Father (67)	Divorced	Alcohol
12	Daughter (50)	6–7	Divorced	2	Father/mother (deceased/72)	Divorced	Alcohol
13	Daughter (35)	Early childhood	Cohabitant	0	Father/mother (64/deceased)	Divorced	Alcohol and drugsa,b
14	Wife (66)	Always, but escalated over past 15 years	Married	1	Husband (68)	Married	Alcohol
15	Cohabitant (65)	Always	Partnership	2	Cohabitant (68)	Cohabitant	Alcohol and drugsa
16	Wife (57)	Always, but escalated over past 9 years	Married	2	Husband (67)	Married	Alcohol

^aDrugs that were used were prescribed addictive psychotropic drugs. ^bOnly the mother was using drugs. ^cFirst the father and later also the mother.

Nine interviews were conducted via telephone and five through Facetime or Skype due to the COVID-19 pandemic. Only two interviews were conducted face-to-face, one in a private home and the other in a meeting room at a voluntary organisation. All interviews were conducted by the first author (AJ). A professional typist fully transcribed all the interviews verbatim within 2 weeks of each interview. Quality control checks were performed by AJ while listening to the interviews and reading through the transcripts. The interviews lasted 17–38 min (total 437 min; mean 27 min).

Interview protocol

We applied a semi-structured topic guide based on three open-ended questions (see Table 2). Follow-up questions were asked to elaborate on the participants’ initial responses. The interviews were based on an interview guide with three open-ended thematic questions that focused on the participants’ experiences with their older family member's problematic substance use (Table 2). Depending on the replies, the aspects and ideas raised by the participants led to further questions to obtain additional information.

Table 2.

Overview of the three thematic interview questions

How do you experience your family member's alcohol and/or psychotropic drug use?

How has this affected/does this affect you in your daily life?

How does it affect your family?

Analysis

Our chosen mode of analysis was Steger's (2007) three-step method. Steger views metaphors as tools for deciphering tacit meanings in participants’ narratives. The first analytical step involves metaphor identification and selection. The two first authors and the last author (AJ, A-SH and KT) were “parallel readers” to broaden the scope of discovery and to facilitate comparison and discussion of the selected metaphors. In our search for significant metaphors related to participants’ lived experience, we looked for repetition, elaboration, relatedness, contrast and emotion, as suggested by Steger (2007). Most of the metaphors characterised the experiences of the interviewees’ parent's or partner's problematic substance use, the participants’ own feelings and experiences, and their relationship to their family member's problematic substance use. These ontological metaphors (Lakoff & Johnson, 1980) were used by the individuals to describe and understand their own experiences that had a bearing on how they handled being a female and having a close family member with problematic substance use. These metaphors about other people and their actions are what Lakoff and Johnson (1980) call “structural and orientational metaphors”.

During the second analytical step, we reflected on the chosen metaphors more generally, for example, in terms of relevant research, local service provisions, and the broader cultural and social consequences for families living with alcohol and, perhaps, other substance problems. During the third step, we returned to the interviews to explore the meaning and implications of the metaphors in participants’ narratives. Steger (2007) describes the third step as a creative endeavour to gain a deeper understanding of the metaphor. This has led us to aim for an in-depth appreciation of the interviewees’ situation, life and emotions. Crucially, by gaining this new knowledge, we also hope to contribute to improved care.

Ethics

The study follows the ethical principles outlined in the Helsinki Declaration (World Medical Association, 2013). The Data Protection Service found that the Norwegian Health Research Act was not applicable to this study, so the study did not need approval from the Regional Committees for Medical and Health Research Ethics. Informed consent was collected from the participants after they had received oral and written information about the aim, design and data protection of the study and before the interviews took place. The participants were also told that they could leave the interview and withdraw their information at any time, but not after the analysis had started.

Empirical results

Our analysis identified four main themes, each with two subthemes as described in Table 3.

Table 3.

Overview of the main themes and subthemes

Main themes	Subthemes
Experiences	Chaos and crash
	Walking on eggshells
Strategies	Being an accomplice
	Silencing
Dilemmas	A deceit or a disease
	Open or closed dilemmas
Consequences	Obtaining or retaining a self
	Health and different types of help

Experiences

Chaos and crash

Both daughters and wives described family life with a parent or husband with problematic substance use as chaotic, unsafe and uncertain. Unpredictable circumstances limited the possibilities to look ahead and plan a future.

A daughter who grew up with a mother who had problematic alcohol use stated: “It was unsafe. Being a mother to a mother who drank episodically, with intervening periods when things were okay. So, it was always a rollercoaster ride alternating between safety and unsafety” (Participant 2).

The instability and insecurity could be extreme. A daughter narrated: “In the evening my mother disappeared, and I never knew when she would return. It became my responsibility to calm and comfort my two younger siblings” (Participant 5). As a 7-year-old, she functioned as a mother for her siblings. Another daughter described how her father alternated between outbreaks of great anger and deep regret the next day: “It was storm and rage. It was extremely contrasted, raising all kinds of emotions simultaneously. I was angry; I was sad; I had a bad conscience. I felt everything. It became chaos. I didn’t feel well” (Participant 6).

Wives reported how their husbands’ personalities changed when they were drinking. They became more irritable and aggressive, which further added to the wives’ stressful and unpredictable lives:

Well, it's very much [about] temperament, what I call mental violence. He hasn’t been physically violent; it's misuse, screaming, shrieking, malice (…) acting out, throwing things, slamming doors. Hullabaloo. There has been very much agitation, which has made family life very stressful and strenuous. (Participant 4)

She goes on to state that she and her children once had to escape from the home because of an incident.

There were times when the husband's drinking used to be more controlled, or he was perhaps described as a “cabinet drinker” – someone who concealed his drinking – or a periodic drinker. These husbands were in their 60s and had recently retired. The wives used expressions such as “he's lost his grip” (Participant 15), he's lost his “foothold”, or he has “crashed” or “cracked”. A wife explained the change that accompanied her husband's retirement and loss of valued leisure activities: “He had to fill a void (…). He found his work very engaging and interesting. I think a very important part of life disappeared very abruptly” (Participant 14).

Walking on eggshells

Whether the person with an alcohol use disorder was a silent or a violent person when drinking, the children and wives were always on alert, attentive and anxious. A daughter said: “I never brought any friends [home] with me after school. I sensed only insecurity. It was like walking on eggshells. For no reason he could explode and get furious, fly into a rage” (Participant 6). This extraordinary sensitivity is described by another daughter through the metaphor of “antennas” and­ tactile hair:

I think many children have antennas, tactile hair far outside their bodies. I grew up in the countryside, and I could nearly feel it when I passed the alley. My senses said, “Now it's going on”, and then it was confirmed when I came inside and felt the atmosphere in the house. (Participant 1)

Another daughter said that her family members were “tiptoeing” around (Participant 8).

In addition, the wives described being ever alert and attentive. One wife used the metaphor of “walking on needles”. She said: “I walk on needles, and I think that when the kids grew older, they did, too” (Participant 15).

One of the interviewed wives summarised the situation as totally absorbing. Her use of the metaphor “engulfing” is telling:

It has been – what to call it? – engulfing. Even if he hasn’t drunk alcohol every day, or every week, maybe once in a month, it's smouldering, and you think, “When will the next period come? When will the row erupt?” (Participant 4)

Because he becomes very angry when drinking, all the family members constantly wonder “When will it blow up again?” Ordinarily problematic alcoholic use is referred to as “it”, an impersonalised way of referring to the dramatic life situation and hiding one's emotions.

When they were away from home, the interviewed daughters and wives worried that there might be an accident, and these worries escalated as the person with problems grew older:

When he combines sleeping pills with alcohol, he remembers nothing. Then he stumbles on the stairs, throws up or lights a cigarette in bed. The combination is highly dangerous, and I’m extremely frightened that such things will happen when I’m away. And what I’m most concerned about is his health. (Participant 3)

Strategies

Being an accomplice

A daughter used the word “co-alcoholics” to express her feelings of culpability in relation to her and her sibling's efforts to hide their mother's drinking from others. She explained: “We siblings didn’t know how to handle it. Our common task became to hide it (the drinking) from other people” (Participant 1). Some wives similarly represented themselves as “co-dependent”, as complicit in their husband's drinking. Seeing the husband suffer from depression or anxiety, some might even supply him with alcohol as in the following narrative:

I fully understand that I’m a sort of accomplice, a partner. I think it's very, very hard to know that I sometimes arrange for his continued drinking (…), if he's very, very downcast and depressed, filled with anguish and stress. It's happened that I’ve bought a bottle of alcohol. It's so totally against everything I really stand for. This is hard to know. (Participant 3)

Her need for some evenings alone when he falls asleep also motivates her cooperation: “In this way I’m complicit in his alcohol use, no doubt”. She also reflected on her ethical boundaries: “I’ve thought about my moral limits for what I find acceptable. I find that I’ve started to push them further, to accept more than I really wish or like” (Participant 3). Her husband's threats to leave her, more frequently as he was getting older, has compelled her to further acts of complicity. Participants acknowledged that their actions and coping strategies may be contributing to their family member's highly problematic alcohol use in old age.

Silencing

A main theme in the stories of both participant groups was the silencing of problematic alcohol use within the family, to keep it out of sight for outsiders and often also to other members of the family. A daughter growing up as an only child living with an alcoholic mother never talked about her mother's drinking to any adult, and conversely, not even the family doctor mentioned it to her. She commented, “Never! I reacted physically, became unwell, had many headaches, and complained a lot. They always examined me, but never talked to me about it [the drinking]. It was taboo!” (Participant 12). In this context, taboo is a recurrent metaphor. Keeping quiet about the alcoholism took place in different settings. She, like other participants, talked about living in a small place where everyone knew everyone. Silencing became more pressing and pervasive in everyday life, as the following quote shows:

I come from a very small town. I think they understood Mama so well that they didn’t want to be involved. I could be invited to a sleepover because Mama was ill, had the flu – but the alcohol problem was never touched upon. (Participant 2)

Another daughter, also growing up with a divorced mother with problematic alcohol use, stated: “I grew up in a very respectable part of the town, where you’re expected to protect your façade. So, I never talked about it to others” (Participant 4). Families may also practise shared silencing, as understood in the following comment: “When (as an adult) I talked about my childhood on social media, it was not well-received in my family. It's the elephant in the room. It shall not be talked about with others!” (Participant 9).

Excessive use of alcohol had a gender aspect. A daughter with two parents misusing alcohol attributed silencing to both gender and generation: “My mother has told me that when she was growing up, having an alcohol problem and being a woman was extremely taboo – more than today – but it persists” (Participant 2). She also thinks that treating problematic alcohol use as a taboo is more common among older adults: “That generation are supposed to be so decent that they hide it more than others”. The silencing and covering up can be based on a tacit agreement and strategy in the family. The illusion continues. The daughter says: “She means that no one knew, but everyone knew. My father was openly drunk. No one did anything.” Another daughter alluded to the “animal in the parish”, signifying the shared silent knowledge: “It is such a small place, where everyone knows everyone. It's not so easy to talk to health personnel either. It may be someone you meet at the grocery store or sing with in the choir” (Participant 10).

Some wives who work in the health services are married to husbands with problematic alcohol use. To remain silent seems necessary to protect their husband, themselves and the family façade – and sometimes even their professional work, as the following comment indicates:

It's too close here, even if not everyone knows everyone. It's so open, so visible in a small milieu, a small town and a small rural community. It's very vulnerable. I really think it’ll harm my work. (Participant 4)

In short, their efforts to hide their family member's problematic alcohol use from others may fail. The problems may be revealed when the family member is stopped for drunk driving, arrested for being openly drunk or put in a prison cell for disturbing the peace or disruptive behaviour.

Dilemmas

A deceit or a disease

All the daughters who were interviewed implied that they saw their childhood as an experience of failed parenting and responsibilities – a deceit. If the parents were divorced, the child usually moved between them on weekends and holidays. A sober parent could be seen as an accomplice to the family member with an alcohol use disorder, silencing the situation and not “putting her or his foot down” by presenting an ultimatum such as “Stop drinking or we will end contact!” However, some did take that step. The sober parent could represent a rather safe haven for a while, and the parent with problematic alcohol use could have good periods and be kind. However, even when he or she was absent, the dependency parent could be continually on their daughter's mind. For example, a daughter would wonder “Will he call as we agreed?” Or a quiet period could be threatened by a sudden crash and breakdown. Both daughters and wives expressed reproach when their father or husband with problematic alcohol use would not admit to having an alcohol dependency problem, refused treatment, violated agreements and forgot appointments.

The family member's excessive use of alcohol was often revealed accidently in situations recalled as traumatic. The daughters sensed “something was wrong”, that their parent had become “strange”. A daughter (Participant 2) talked about her “weekend daddy”: “He made me very insecure and ashamed, embarrassed”. As adults, the daughters attempted to regulate their own and their family's contact with the person. Another daughter talked about her attitude now, accepting the disease metaphor: “My husband couldn’t understand how I could forgive such behaviour. Then I’d say, ‘She just does it because she's ill’. If I recollected all the bad things she's done, then we’d never have any contact” (Participant 1). A third daughter reflected on the differences in the attribution of causes: “If I refer to problematic alcohol use as an illness, then there's not as much empathy for these people as there is for those who say, ‘I have cancer.’ It's really stigmatising” (Participant 7). Even so, the illness metaphor makes the problematic drinking pattern more sensible and acceptable.

All the wives held their husbands responsible for their problematic alcohol use, especially at the earlier stages, until it became obvious that they had lost control. A wife admits:

I’ve felt much shame and contempt for him, despite my knowledge about alcoholism and addiction. Thinking, “Why couldn’t you just (stop)?” or “What a miserable man he is!” I went into that trap. It was a lot of negative thinking about me and him. (Participant 16)

The hidden drinking, breaking any agreement or at an event when the wife is away, is also felt as deceit in older age.

Another wife talked about the emotions caused by his “deceit”, a term she uses in the following way:

It's a mixture of anger, sorrow and disappointment (…). I see that he's deceived me systematically over many years (…). I feel I’ve failed (…). I strive [to agree] with the concept of illness because it has proceeded for so many years, and he has gotten help without any effect. I find that he's played to the gallery, so that he could continue as before. This is what I’m angry about! (Participant 15)

It seems to be very difficult for the participants to adhere to the concept of alcohol use as an illness. A daughter reproached her stepfather for being too lenient by giving her mother the illness role and then pitying her. “For me, being tough isn’t easy. You look at her as a patient in a way” (Participant 9).

Open or closed dilemmas

Among the most dominant metaphors in the participants’ narratives are those spatialisation and orientational metaphors referring to borders and circles of people and themes that are placed “inside” or “outside”. The metaphors refer to both social relations and mental reactions. The main question is if and under what circumstances the female relatives have been able to “open up” and inform others and what they want to keep closed, concealed or confidential. To “open up” about something depends on having confidence in others and in their own resources to cope with the consequences. The metaphors applied may seem trivial but have great existential relevance. A daughter narrated the following, which may serve as an example of a closing of feelings and memories:

I’ve blocked many memories, specific events. The mixture of sentiments in situations when you’re very, very ashamed, but also very afraid (…). The solution when I was a kid was to turn off. I’ve shut down my own feelings. I went directly into anger and fight, with rather great consequences in adulthood. I’ve had anxiety very, very, very much. (Participant 6)

The metaphors of “blocking”, “turning off” and “shutting down” emotions and memories underline her limits and borders. Her repetition of the word “very” emphasises the importance; emotions were suppressed, which was also noted by another interviewee who said: “I never cried, ever” (Participant 11). The repression may be transformed to a personality trait. A daughter said: “I’ve become very tough and got a very thick skin and let very few close to me. I don’t crack easily.” However, the situation “may raise anxiety, fatigue. Traumas are caught in the body when you haven’t worked it out” (Participant 1).

Most wives have someone they confide in privately, a person or persons they trust to be discreet, trustworthy and able to keep what the wife shares with them in private. Some wives said that, in general, they have become more “open”, while others have a few special confidants. A wife who lives in a small town has discussed her situation with a neighbour who is also married to a man with an alcohol problem. However, revealing the problem may be a risky endeavour. A wife who tried to tell her husband's friends about his problems felt that they distrusted her (Participant 4). Moreover, the social lives of the families are markedly reduced, and some wives explicitly mentioned feeling lonely and isolated. They are still, even at older ages, reluctant to have guests in their homes, especially in the evenings.

Consequences

Obtaining or retaining an identity

The self is referred to as an essence – a thing – to be gained or lost. The daughters underlined how their insecure and unpredictable childhood made them insecure and unstable. They described their self-constructions in various ways. One said that she turned silent and withdrawn, another found that she wanted to please everyone. One daughter became openly self-destructive: “I had a terrible time at school, started drinking when I was 12 and experimented with drugs. This was normal where I came from” (Participant 11). She was self-effacing:

I’ve not focused on myself. I’ve really been most engaged in fulfilling other people's needs. This has followed me all my life (…). I’ve annihilated myself. That is unhealthy! So, I’ve had mental health problems all my life. (Participant 11)

The self is described as a thing that has not been developed. Another daughter has, as an adult, defined some limits of self-destruction by the metaphor “of being eaten”: “I’ve decided that I can’t involve me so much that it eats me up. I don’t want this situation to define me” (Participant 1).

In contrast, the wives narrated their stories by stressing how they gradually lost their sense of self by living with a man with alcohol dependency. One remarked:

I think that was the reason why I became ill (…). In the end I didn’t know who I was. What was the difference between him and me? I had no experience of having a self. It was like it was crumbled up. (Participant 16)

Her self had disintegrated. She described feeling “like one of Pavlov's dogs”: “It resulted in my experience of having lost myself. I mean, I’ve only reacted, not acted. I haven’t been in the driver's seat in my own life, see?” (Participant 16). The daughters described feeling that they had not developed a solid self, and the wives – now in old age – felt that their former selves were lost.

Health and different types of help

All the participants discussed the health consequences of living with a parent or husband with problematic alcohol use. The most prevalent consequences were depression, anxiety and fatigue. In their narratives, the participants use relatively few metaphors when talking about their psychological health and reactions. They usually applied the diagnostic terms incorporated into everyday language; for example, a daughter talking about her siblings commented: “They’ve got anxiety, fatigue” (Participant 1).

All female relatives, but especially the daughters, stressed how their health and life projects had been and continue to be negatively and seriously affected. A daughter said: “I’ve been very ill – a ‘swinging-door’ patient of psychiatric institutions (…). I have no education. I’m poor and I have no job as a consequence of those years” (Participant 11). Anorexia and self-destructive behaviours followed.

Some participants described having negative experiences with professional help, even those with a family approach. A daughter with extensive experiences of various treatment programmes said: “Nearly none (of the professional helpers) have really seen the family” (Participant 1).

More often, however, metaphors have been applied for physical problems and symptoms. A wife referred to her physical reaction as having “a lump in her stomach” (Participant 3). In (Norwegian) everyday language, the stomach is designated as the seat of worries, as presented by this woman. For some women, health problems escalated and resulted in their need to take sick leave. Another wife commented: “At times, I’ve been on sick leave for a longer time. I nearly reached fatigue, was exhausted and constantly tired because I slept very badly. My sleeping quality was very, very bad” (Participant 4).

Ageing does not reduce their burden, as described by a daughter who sighed: “The older they get, the worse it becomes (…). It's like having two kids.” However, the interviewees’ resources for coping and for managing the situation may increase. Several talked about exhaustion: “How to live in constant worry and fear, being totally exhausted. It's a very long time since this happened. You’re grown up and should [be able to] manage this. But I’m totally worn out by life” (Participant 5).

All the participants had received support from volunteer organisations or participated in individual or group treatment programmes, but they did not talk about the setting, structure or content of their support or treatment. Neither did they discuss their expectations; they only spoke about how they experienced being met by the staff. Some special persons seeing them are noted as decisive in their recovery. A daughter talked about her “road to destruction” and the first professional person that could help her, a “personal and human” psychologist. “He was ‘the unprofessional professional’.” She summarised the element that really helped her: “They have met me where I’ve been, and when I’ve been there” (Participant 11). Another daughter commented that talking with the family physician was very helpful (Participant 6).

However, despite adequate help that provides “tools” for recovery, the healing may take place gradually, in steps (Participant 1). Shared statements referring to treatments indicate that they have “opened up more”. “It's been a relief, really, not to shine it up or conceal it”, mentioned a wife (Participant 15). “Playing with open cards” is a recurrent metaphor in her interview.

The therapies differed between individual therapies and group or family therapies. A daughter commented on the psychological therapy: “Rather late, I got anxiety. It (the therapy) focused on the anxiety but didn’t treat everything else – my lack of belonging”. She emphasised the significance of a network. The most appreciated assistance is participating in groups of peers: “Together we’re stronger. To talk to others who have (…) Without knowing each other, you suddenly sit there and see. I’ve experienced just the same” (Participant 9). Recognising that they are not alone and that they share extraordinary experiences is a relief and a move towards recovery.

Discussion

We have analysed interviews of daughters and wives of individuals with problematic substance use over many years and into old age. The most significant ontological metaphor applied by the participants was chaos, signifying lack of control and possibilities to impact the structures and contents of their everyday lives. The interviewees lack basic safety and confidence in their substance-using family members, and this limits their ability to have lives with fundamental trust and comfort. Chaos has made it impossible to be prepared emotionally, cognitively and proactively – to apply coping strategies supporting, developing and sustaining a solid, confident self. The participants used metaphors such as walking on eggshells or needles and tiptoeing to describe their frail, unstable and ever-attentive emotional and cognitive mindset. They could not dwell in a state of relaxed confidence to have a positive and productive everyday life. A shift towards a repertoire that includes fighting metaphors may be a sign of a strengthened self-confident family member.

Most of the metaphors found and analysed in our study were common, often structural and orientational, used in everyday speech, and the analysis revealed how they were interrelated and indicated ontological meaning. Idiosyncratic metaphors and innovative individual images were rare in the participants’ stories. They preferred to convey their experiences in words that were rather easily understood.

We found that the metaphors often indicated images of circles, with borders and limits that placed the participants in their social world inside or outside the circles. They applied structural and orientational metaphors. The circles were usually narrow, with well-defined and rather rigid boundaries regarding participating in and sharing their experiences, emotions and life situation with others. The interviewees felt that it was unsafe to participate in normal everyday social activities.

The interviewees had very few trusted people with whom they could share their stories of living with a person with problematic substance use. Some of the daughters had no one to confide in for many years. The participants used illustrative spatial and figurative metaphors of lines and circles to position themselves outside a regular life, having a very restricted space for work and social activities with hobbies and friendships.

The orientational metaphors divided the world; outside, there was shame and contempt, taboo, ostracism and social avoidance. The participants distanced themselves and felt that others kept them at a distance. The images of a person with problematic substance use signalled immorality, lack of decent and respectable behaviour, control and responsibility – falling outside normality. These images were relevant to the whole family. Nearly all participants stressed aspects of stigma connected to alcohol problems. Our results are in line with those of O'Shay-Wallace (2019), who demonstrated how families managed the stigma of substance use problems by concealing the problem from others by silence. The studies of McCann and Lubman (2018a, 2018b) also supported the study by O'Shay-Wallace (2019).

Furthermore, the “circles and boundaries” metaphors led to an understanding of how they could expand their spaces and decrease their boundaries towards their surroundings by finding ways out of isolation and shame. They accentuated the participants’ longing for being part of groups of people who recognise and share their experiences, people who see, respect and support each other. Several studies have examined the impact of a family member's alcohol problems on other family members (Di Sarno et al., 2021; McCann & Lubman, 2018a, 2018b) and relatives (Newton et al., 2016). Regarding the consequences of living with a parent or husband with problematic alcohol use, our study found that the participants’ metaphors, such as walking on needles, having a lump in the stomach and keeping out of sight as well as being a swinging-door patient in psychiatric institutions, pointed toward anxiety, depression, and a sense of being an outsider and not belonging. These results are consistent with those in a study by Newton et al. (2016), which found that many people sought help for anxiety and depression related to alcohol and other substance use problems, either their own or those of a family member.

Caring by women has been called “a labour of love” (Finch & Groves, 1983). The wives have asked themselves why they do not leave such a marriage. They mentioned that many factors hindered them or put boundaries around them that made it difficult to leave a spouse with alcohol problems. These could include other people's opinion, the couple's shared production means and estates, lack of work and housing prospects, economic difficulties, consequences for their children and the wider family, and shifting alliances. Moreover, a husband's sober periods confirmed the bonds of the marriage and his positive qualities, aptly summarised in the expression “He's lovely and awful” (Hellum et al., 2021).

The recovery tradition within mental health services emphasises the value of a predictable and supportive everyday life (Borg & Davidson, 2008). Our study has documented the great importance of the special persons that the participants have “opened up to”. Some said that these individuals had helped them cope. These could be health personnel but also people in the neighbourhood. Previous studies have also underlined that family members of individuals with alcohol problems need support of various kinds and have highlighted the value of informal sources in the support structures (Di Sarno et al., 2021; McCann et al., 2019a, 2019b).

The participants mainly perceive alcohol dependency as a moral weakness and a deceit. It was conceived as a betrayal of the family and its social functions. They accused the person with an alcohol disorder of failure to admit the problem, denying and concealing it and refusing to get treatment and stick to a sober lifestyle. By contrast, the illness metaphor places the problems outside the moral sphere, indicating respectability, human concern, the need for healthcare treatment, and inclusion and acceptance of the health and welfare system. According to Sontag (1978, p. 13), the disease is “up” (increasing understanding and empathy) when it comes to directional metaphors, while deceit is expressed as “down” (decreasing understanding and empathy). The idea of a disease provides respect and social support and decreases stigma, while deceit due to alcohol problems leads to disrespect and social rejection. At the same time, and from the perspective of close family members, a diagnosis of illness may make it more difficult to leave the marriage – wives do not feel it is morally right to leave their ill spouses (Thorsen & Johannessen, 2021). We found that the family members of a person with problematic alcohol use often feel obliged to act as accomplices to hinder the outbreaks, hide the problems and avoid the shame.

Our metaphorical analysis has documented the unpredictable and uncontrollable behaviour of the person with problematic alcohol use. Such behaviour undermines the daughters’ development of a solid self and the wives’ sustainability of an established self. The daughters, in particular, revealed their significant problems related to the establishment of trust in others, coping and attaining a positive quality of life.

A review (Meyers et al., 2021) shows that very few quantitative studies (out of 75) report any gender differences in drug-related stigma, while nearly all the qualitative studies (97%) demonstrate that women experience higher levels of stigma. Another study indicates that being a female, having a lower socioeconomic status and cohabitation are connected to higher levels of stress, strain, stigma, self-blame and social isolation (McCann & Lubman, 2018b). We may see silencing, secretive behaviour and social isolation found in our study as a part of the stigma experiences.

Among family members affected, stigma was said to be a barrier to seeking help, which is also underlined in other studies (Birkeland, 2019; McCann & Lubman, 2018b; O'Shay-Wallace, 2019). A Norwegian report stated that most family members referred to specialist treatment due to a relative's substance use were women (Kristiansen & Myhra, 2012). Professional treatment and assistance may also be a way for the partners or family members to increase their confidence in themselves and others, to “open up” their circles and to find a path to a better life.

According to some participants, their problems attached to the burden of having a family member with problematic substance use did not reduce when they grew older. In several cases, the problems may in fact have increased. The parents’ helplessness and caring needs were found to increase, along with exhaustion and fatigue among the daughters. A study points out that the social and emotional burden related to caregiving is harmful when caring for a person with a problematic alcohol use (Rospenda et al., 2010). Another study shows that problems within one's own family exacerbate the complex challenges they face (Tedgård et al., 2019). The affected family members may feel fearful and without hope about the future (McCann et al., 2019a, 2019b). A few of the participants seemed to be in that state, but most of them reported that the support they had received from the treatment they attended, especially regarding meeting peers, had “opened up” possibilities, strengthened their resources and given them hope for a better life. Studies of peer support underline that such support is experienced as important (Mead & MacNeil, 2006; Repper & Carter, 2011). Our study confirms that meeting others who share their life experiences has strengthened them and increased their self-confidence.

A recent review of studies on the impact of dementia on family members pointed out the lack of differentiation by gender and generation in published studies (Arbel et al., 2019). Our study of female family members affected by problematic substance use underlines the necessity of differentiating between generations. The effects of substance problems on daughters and wives differ. Our study included only female relatives, and thus it is left to also study the nature of gender differences for male relatives.

Strengths and limitations

The strength of our study is its revelation of how metaphors offer opportunities for condensed and figurative verbal experiences and relate them to each other. Metaphors powerfully condense experiences and emotions that are difficult to discuss. The metaphors in our study convey and connect emotions and actions relating to extraordinarily complex and challenging living circumstances – life with parents and husbands with problematic substance use.

The analysis of metaphors has uncovered how descriptions of life situations and social interaction entail more than themes and storylines. Our analysis shows how the themes can be both entangled and coherent. One image is meaningfully related to another: life experiences are associated with strategies, and they imply dilemmas and lead to consequences.

Our metaphorical analysis also has its limitations. When the aim of research is to gain a better understanding of how female family members experience and are affected by substance use problems, other qualitative methods, such as a longitudinal qualitive study design, may be more appropriate.

Another limitation was that the participants were recruited from two hospitals and three voluntary organisations. These participants might have greater resources and might be more used to analysing and problematising their situation than those who have not been in contact with hospitals and voluntary organisations.

In addition, 14 out of 16 interviews were performed by telephone, Facetime or Skype and not face-to-face because of the COVID-19 pandemic. This may have affected the bond between the interviewer and the interviewee and, for example, the depth of the conversation.

Conclusion

Family life with a parent or spouse with a substance use problem was described as chaotic, unsafe and uncertain, and with no prospects for change. The study illustrates how metaphors are used to mediate experiences and worldviews pertaining to existential matters founded in deep negative emotions, deceit, shame and stigma. Metaphors make up a crucial material for communicating emotions and themes that are difficult to convey due to shame and stigma. Peer support and being among equals are especially valued as helpful.