The Intersection of Adoption and Addiction
Adoption Advocate No. 166
Little education and training exists on the intersection of addiction and adoption. As the director of Adoption Programming at PACE Recovery, and an adopted individual, Dr. Brett Furst offers his expertise on this important topic, to encourage and guide both adoptive parents and professionals towards a better understanding of the disease of addiction and how to help hurting adoptees.
Addiction is a disease of escapism. While each person who suffers from a Substance Use Disorder (SUD) has unique underlying difficulties that cause them to seek this escape, the fundamental reason for turning to substances is rooted in a lack of ability to manage or navigate one’s reality. Addiction is a solution to a problem that the user sees as unsolvable. It is not something to shame or belittle them about. They are not abusing substances because they are unintelligent or do not understand that it is bad for them, or because they truly think they are invincible. They are doing so because they are hurting.
While a lot of the content in the following article may seem scary or daunting, as the author I am coming from a place of hope about the future of adoption and addiction treatment. My very first exposure to adoption was my own, followed by that of my sisters, and now all the clients that have come through my practice. While “adopted” is enough of a label on its own without adding “addict,” neither word ever needs to be negative. Just as there is strength in being adopted, there is strength in overcoming addiction. The intent of this piece is not to stigmatize adoptees as people who will develop addictions, but rather to encourage both parents and clinicians to learn more about the disease of addiction and help bring the proper services to those adoptees who are in pain.
What is Substance Use Disorder?
Substance Use Disorder (SUD) can be defined as continued use of substances despite adverse consequences. There are other technical criteria related to duration of use, situations around using, tolerance, and withdrawal as well, but at its core SUD is defined as a state in which a person sacrifices their quality of life for continued use of one or more substances.
For those of us who have healthy and stable attachments, we are able to utilize our loved ones and the attachments around us as a functional and productive means of escapism. We find comfort in the ability to be vulnerable with someone, and to have them care for us and about us. For adoptees, they may not have that option. Not only do some adoptees lack the skills or ability to attach to others in a supportive way, but their need for escapism often comes from a different and more complex place than their non-adopted peers.
What is Attachment?
Attachment defines the ways in which we connect to the world around us. While attachment is not limited to people, attachments to other people are vital and critical; lack of access to attachment is akin to losing access to food or water.
Studies have shown that individuals who have been adopted are almost twice as likely to develop a Substance Use Disorder as those who were not adopted. In treating substance abuse, a variety of factors contribute to the unique manifestation of symptoms in each individual receiving treatment. Biological factors (e.g., parental substance use history) and environmental factors (e.g., criminality and divorce in the adoptive family) have been found to be difficult to parse out, in terms of their overall impact on the presence of substance use. This is due to the fact that there are often significant overlaps between the two categories of factors. Whether it is the presence of comorbid disorders, family discord, or attachment-related issues, there is often a lack of clarity regarding how each of these factors, if any, contribute to increased substance use in adopted individuals. Thus, in treating adoptees with SUD the “why” becomes less important than the “how” of treatment methods.
Adoption and Substance Use Disorder
While addiction is a disease of escapism, it is also a disease of attachment. Researchers exploring the relationship between attachment and substance use have noted that those with attachment insecurity are at higher risk of an SUD, while also noting that particular patterns of attachment insecurity are linked to specific substances (e.g., fearful avoidant attachment patterns in those who abused heroin). Alcoholics Anonymous often speaks of the “God-shaped hole” that addicts can struggle with. Miguel Caballero, who pioneered Alcoholics Anonymous for Adoptees (AAA), writes about the “mom-shaped hole” that is often unique to adoptees who struggle with addiction.
For each adoptee struggling with SUD the starting point in treatment is their attachment health, or more specifically, their attachment fears. When adoptees crave attachment but also view it as the greatest threat to their safety, they often look for ways to soothe or distract themselves from this fear. Whether is it the solo user who isolates, or the user who crafts a “substance using family” for themselves and assuages their attachment fears by getting high, adoptees who abuse substances are looking for a way to feel some form of attachment.
Isolating users are dealing with the loneliness and depression that comes with fear-based isolation and detachment by artificially raising their mood or distracting themselves from their oppressive emotions by getting high. These adoptees often present with a blanket mistrust of the world and a very low bar for rejecting the attachment of others. They operate under a “separate but safe” mentality, often without insight into how this pattern is self-perpetuating and stems from their attachment fears. Substances often become an attachment figure for them, and the idea of sobriety can be terrifying, not only because they have to face all of the things they have been running from, but because they are losing their most consistent attachment object.
Adoptees who use with others use substances as a tool to form superficial attachments to those around them; substances allow them to quiet the voice of fear that pushes them to be mistrustful and run away. These individuals often form “using families,” groups of peers tied together by their substance abuse. Sobriety for them also means a loss of attachment, as once you remove substances from the using family, that family falls apart. These individuals operate under a “something is better than nothing” mentality, when in reality having relationships that lack depth and vulnerability only highlights the adoptees’ inability to connect and their grief about not having their attachment needs met. In each case, and in cases that do not fall in these two categories, we see adoptees using substances as a tool to help them face a fear they see as insurmountable. As clinicians, it is vital to remember that this is what substance abuse is so often about.
According to the father of Gestalt therapy, Fritz Perls, inauthenticity occurs when “there is a big area of fantasy activity that takes up so much of our excitement, of our energy, of our life force, that there is very little energy left to be in touch with reality.” When looking for a starting point in treating adoptees with SUD, I have found that inauthenticity is the most universally applicable starting point to dismantling the behaviors that keep them in their attachment-based fears. For adoptees, their reality often feels disconnected and confusing, and so they look to craft a version of themselves that is both safer and more accepted by those around them. Often, this inauthentic persona has been building since childhood and has acted as a consistent security blanket. While inauthenticity is often aimed at making us more likeable to others, at its core it is a protective mechanism. If I am rejected while I am being inauthentic, I do not feel that it is a true rejection because I was not being my true self. Inauthenticity allows adoptees to stay separate but safe, even when they are around and engaging with others.
There is, understandably, a lot of fear associated with letting go of inauthenticity. For adoptees, the process of letting go of this lifelong defense mechanism can bring up some fluctuations in behavior that needs to be monitored in a treatment setting. For each piece of vulnerability or insight the adoptee gains, there can be an opposite behavioral outburst. I have dubbed this the “yo-yo effect” in my own practice. It stems from the conflict between the desire to be more authentic and lay down the exhausting burden of inauthenticity, and the fear of facing reality without a primary defense mechanism. Clinically, it is important to help adoptees ride these behavioral waves and continually push through towards continued insight and vulnerability.
Personally, I have found Gestalt therapy to be highly effective with adoptees in general, and especially with authenticity work. I find its emphasis on authenticity comforting and refreshing as it meshes perfectly with the uniqueness of the adoptees I work with as well as all the other clients I see for SUD. The most important tenet of Gestalt therapy is its emphasis on the authenticity of the clinician. This can be an uncomfortable experience for a lot of clinicians as we are often taught to keep ourselves separate from the therapy room for fear of placing our biases or countertransference on the client. I believe it is unethical to ask something of our clients that we are not willing to do ourselves—and with adoptees, this is doubly important. We need to model and be a safe place for our adopted clients to explore moving through their inauthenticity, a process that for many has been one of their greatest fears.
In addition to maintaining your own authenticity, when working with adoptees in SUD you must become comfortable with being an attachment figure for them, albeit a temporary one. As you push them to be more and more vulnerable and authentic, you are also modeling what healthy attachment, including boundaries, looks like. There is a level of intimacy that occurs when working with this population that can often be uncomfortable and difficult to navigate. For example, these clients may become overly sensitive to perceived rejection/abandonment by clinicians. This could occur when a session time must be changed, or a client feels they need to speak with a clinician urgently while the clinician is in another session with someone else. It could also occur when a clinician seeks to initiate termination or to reduce the frequency of sessions. This level of intimacy can also be uncomfortable for clinicians because we are often explicitly taught not to allow that kind of deeper or “boundary crossing” intimacy with clients. It is important to use your own clinical support system to navigate this, and to check with your professional peers to help keep the therapeutic intimacy with your clients at an acceptable, productive level.
Unfortunately, there is not much education and training on how to treat adoptees with SUD. I personally offer training programs to agencies and treatment centers, but even those are largely based on my own experiences and models for treating this population. Research on which treatments are effective and which factors influence SUD presentation in adoptees is severely lacking, and as a field we seem to be flying blindly with the best intentions. The most important thing you can do as a clinician is treat this population with openness and authenticity and be willing to meet the client in their fear. Adoptees in SUD may take more effort and more time than the non-adoptee population and will most likely need more treatment overall. Be active in curating resources for your clients that feel authentic and helpful to you, and refer them out if you think you are not the right fit. Ask adult adoptees in recovery from SUD about their experiences and be open to the uniqueness of each adoption and addiction story. Be curious and stay curious. The work is worth the outcome.
A Note for Families
Addiction is a scary word. It conjures up images of injury, homelessness, irreparable damage, and death. While all those things are very real consequences of addiction, the association between addiction and these terrifying visuals often pushes us to treat an addict with fear, aggression, guilt, and panic. Parents will often ask, “Where did I go wrong? Don’t they understand what they are doing? Why can’t they just stop?” We might feel betrayed by our loved one, scared for their lives, and angry because we do not know what else to feel. While these are all valid emotions and responses to the life of your loved one being threatened by a disease, this is not a standalone disease. Rather, it is a symptom of underlying pain that should be treated with compassion. “Scared straight” does not work, and in many cases increases the rates of substance abuse in those who are exposed to such programs. Even the D.A.R.E. program, which was once the staple of American anti-drug education, was shown to increase rates of substance abuse in children exposed to it. We know that reacting with anger, shaming, and guilt does not stop addiction from developing.
New research shows that early and consistent education on emotion management and mental health are the best preventors of later substance abuse.Adoptees may struggle with feelings of abandonment, depression, anxiety, and a whole host of other emotions uniquely powerful to them. But if they are taught how to manage, respect, and work through their emotions, they will be less likely to seek substances down the road. If they do end up struggling with addiction, it does not have to be a death sentence. Yes, they may need to be sober for the rest of their lives and will need to learn to live with the label of “addict” but some of the absolute best human beings on this planet are sober. Having to go to treatment or “rehab” is never a bad thing; it means you are getting the help you need to move forward with your life and be your best, authentic self. Addiction does not need to be the scarlet letter it has been historically, and it can serve as a fantastic growth opportunity not just for the one who is struggling but for everyone who loves and cares about them.
More important, perhaps, than how you treat the struggling member of your family is how you take care of yourself. Anecdotally, in my clinical work the primary predictor of individuals not completing treatment or failing in sobriety is the parents and family not being solid in their own attachment and boundary work. Most of the time, the family has just as many, if not more, attachment-related problems as their loved one. Families, you cannot take care of someone else if you do not take care of yourself. Go to therapy, find support groups, set boundaries, and trust your treatment professionals. The whole family system has to change in order for an addict to recover, so it is better to be an agent of that change than to fight the process.
Frequently Asked Questions
Should parents talk to their adopted children about this risk of developing SUD, especially if there is a known history of SUD in biological family members? If so, how can parents begin these conversations, and what is important to communicate?
No child is too young to start learning emotional identification and management, which are the keys to preventing later substance abuse. When age-appropriate, talk to your children about the risk for SUD, but remember that the goal is not to instill fear. The “scared straight” method does not work. It is important to come from a place of educating and concern while also honoring the fact that your children are intelligent.
Knowing that there is a lack of resources, do you have suggestions on how professionals and the families they work with can access adoption-competent SUD resources and professionals?
It is crucial to stay open-minded and connected to the community. Find others who have gone through the same thing or have expertise in adoption and addiction. Families, do not be afraid to try multiple therapists until you find one that fits. Grow Beyond Words provides a directory of adoption-competent therapists who are also adopted themselves, and is a great resource to seek out adoption-competent therapists. Clinicians, do not be afraid to reach out for help and education from your peers, and be active in creating more resources and research for this population.
Addiction is taboo in our society, with many individuals avoiding thinking or talking about this topic in the hopes that it won’t manifest in those we care about. But this lack of awareness and avoidance of the issue often has the opposite effect. The correlation between adoption and addiction exists, and both families and professionals need to be able to address it with full knowledge and open minds. The intent of these conversations is never to put fear into anyone’s heart. Being an adoptee is not a curse that dooms one to struggle with addiction, and being an addict does not condemn one to a life of pain and loss. With research, practice, intent, and hope, professionals can continue to help these adoptees and ensure that SUD continues to be treated in the most progressive and effective way possible.
 National Institutes of Health. (July 2020) Drugs, Brains, and Behavior: The Science of Addiction Drug Misuse and Addiction. Retrieved from: https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/drug-misuse-addiction
 Yoon, G., Westermeyer, J., Warwick, M., & Kuskowski, M. A. (2012). Substance use disorders and adoption: Findings from a national sample. PloS one, 7(11), e49655. Retrieved from https://europepmc.org/article/PMC/3499473
 Kendler, K. S., Sundquist, K., Ohlsson, H., Palmér, K., Maes, H., Winkleby, M. A., & Sundquist, J. (2012). Genetic and familial environmental influences on the risk for drug abuse: A national Swedish adoption study. Archives of General Psychiatry, 69(7), 690–697. Retrieved from https://portal.research.lu.se/en/publications/genetic-and-familial-environmental-influences-on-the-risk-for-dru
 Burstein, M., Stanger, C., & Dumenci, L. (2012). Relations between parent psychopathology, family functioning, and adolescent problems in substance-abusing families: Disaggregating the effects of parent gender. Child Psychiatry and Human Development, 43(4), 631–647. Retrieved from https://link.springer.com/article/10.1007/s10578-012-0288-z
 Denton, W. H., Adinoff, B. H., Lewis, D., Walker, R., & Winhusen, T. (2014). Family discord is associated with increased substance use for pregnant substance users. Substance Use & Misuse, 49(3), 326–332. Retrieved from https://europepmc.org/article/MED/24106976
 Caspers, K. M., Yucuis, R., Troutman, B., & Spinks, R. (2006). Attachment as an organizer of behavior: Implications for substance abuse problems and willingness to seek treatment. Substance Abuse Treatment, Prevention, and Policy, 1(1), 32. Retrieved from https://europepmc.org/article/MED/17081298
 Schindler, A., & Bröning, S. (2015). A review on attachment and adolescent substance abuse: Empirical evidence and implications for prevention and treatment. Substance Abuse, 36(3), 304–313. Retrieved from https://www.tandfonline.com/doi/abs/10.1080/08897077. 2014.983586?journalCode=wsub208
 Caballero, M. (2018, February 1). Finding the missing piece. Keys to Recovery Newspaper, 12.
 Perls, F. S. (1969). Gestalt therapy verbatim. The Gestalt Journal Press.
 Rosenbaum, Dennis P; Hanson, Gordon S (1998). Assessing the effects of school-based drug education: A six-year multilevel analysis of project D.A.R.E. Journal of Research in Crime and Delinquency. 35(4), 381–412. Retrieved from https://journals.sagepub.com/doi/abs/10.1177/ 0022427898035004002
 Demirezen, D., Karaca, A., Konuk Sener, D., & Ankarali, H. (2019). Agents of change: the role of the peer education program in preventing adolescent substance abuse. Journal of Child & Adolescent Substance Abuse, 28(5), 376-387. Retrieved from https://www.tandfonline.com/doi/full/10.1080/1067828X.2020.1766618
Originally published in 2022 by National Council For Adoption. Reprinting or republishing without express written permission is prohibited.
About the Author
Dr. Brett Furst, LMFT, holds a B.S. in Child and Adolescent Development from the University of California, Davis, an M.A. in Marriage and Family Therapy from Chapman University, and a Doctorate in Couples and Family Therapy from Alliant International University. Dr. Furst specializes in treating adoptees who struggle with substance use. He has created some of the first specialized treatment protocols, therapeutic tracks, and unique interventions to better help this under-served population and has used this background in his role as the director of Adoption Programming at PACE Recovery. Dr. Furst's research in this field has focused on the role that a relationship with one's biological parent(s) has on the severity of substance use and has brought to light the need for increased treatment expertise in the substance use treatment field. Therapeutically, Dr. Furst comes from a Gestalt and attachment perspective, placing emphasis on the exploration of the authentic self and how defensive inauthenticity can contribute to a lack of healthy attachment to others.