Roles and Mental Health Functioning of Adult Children of Alcoholic Fathers in Pakistan

It has been amply demonstrated through clinical practice and research that alcoholism not only affects the individual, but the family as well (Olmsted, Crowell, & Waters, 2003). The affects are numerous ranging from nonclinical to clinical problems (Barnard & McKeganey, 2004). Moreover, one of the salient features is that the family members of the alcoholics, especially, the children regardless of age develop certain psychosocial roles in order to deal with the chaos in the family caused by the parent’s alcoholism (Daylon, 2012). The present study was aimed to study the mental health functioning, the roles assumed by the adult children of alcoholics, and also the relationship between the two variables. In order to achieve the aim, data were collected from private rehabilitation centers where the fathers were admitted for treatment of alcoholism and the family were counseled on outpatient basis. To determine the mental health functioning General Health Questionnaire (Goldberg & Williams, 1988) was used and for the roles Role Identification Scale (Samuel, Mahmood, & Saleem, 2014) was administered on 400 participants with age range 18-25 years with equal gender distribution. The results showed two sets of complimentary roles in the family and their significant relationship with mental health functioning. The relationship between the variables was discussed in context of indigenous family structure and cultural practices along with implications of the study.

Alcoholism is one of those chronic and progressive diseases (Jay & Jay, 2000) that not only affect the individual, but also the family (Wormer, 2008) due to the unpredictable and chaotic environment in the family (Nodar, 2012; Vernig, 2011). For better understanding of the family dynamics of the alcoholic family, the family is conceptualized as a system where all family members interact and are affected by each other’s behavior. For example, when the life of an alcoholic becomes dysfunctional, it has an adverse impact on the other family members as well (Friel, 1988).

Alcohol being an expensive drug, depletes the financial resources of a household (Khan, 1983). The depletion of finances coupled with the abusive and embarrassing environment leads to a lot of stress and strain in all family members (Jay & Jay, 2000). Aggression is a behavior that is quite prevalent in the alcoholic family (Leonard & Eiden, 2007). Furthermore, the spouse of the alcoholic is mostly the target of the aggression (Beattie, 2009; Keller, Cummings, Davies, & Mitchell, 2008) that leads to low self-esteem, anxiety, and depression, etc. (Stanley, 2001). Aggression leading to mental health issues in the spouse is strongly associated with the compromised parenting (Finger et al., 2010).

The literature also highlighted that the adult children of the alcoholics are deemed to be a vulnerable population in terms of normal development in many areas of life such as physical, emotional, cognitive, psychological, and social (Watt, 2002). Moreover, the research has demonstrated that the adult children suffer from a multitude of psychological disorders (Casas-Gil & Navarro-Guzman, 2002), such as anxiety (Alegria et al., 2010), depression (Kelley, Pearson, Trinh, Klostermann, & Krakowski, 2011), and low self-esteem (Cleveland Clinic Foundation, 2009). Furthermore, they are also reported to be prone to alcoholism (Fineran, Laux, Seymore, & Thomas, 2010), attention deficit hyperactivity disorder (Torvik, Rognmo, Ask, Roysamb, & Tambs, 2011), academic problems (Moolakkatt & George, 2012), mismanaged anger (Lee, 2006), and even marital problems later in life (Watt, 2002).

What seem to be alarming is that these mental health issues continue even if the children are no longer with the family of origin or even when the parent discontinues drinking (Hussong, Flora, Curran, Chassin, & Zucker, 2008). For many years, those involved in the care and treatment of the alcoholics and their families have been pointing out that the adult children of alcoholics assume certain roles in the family in order to deal with the chaos, unpredictability, and stress and strain in the family (Sandalson, 2012). These roles that children assume as a results of parental drinking may help them feel in control and deal with the chaos and stress (Daylon, 2012). Although, these roles basically help them survive the ordeal of having an alcoholic parent, but only in the short run (Young & Adamec, 2013), but later these lead to mental health issues (Black, 2006). The roles become rigid with age and lead to difficulties later on in life (Nodar, 2012). It has been demonstrated that there are usually four roles that the children or adult children of alcoholics assume (Wampler, Downs, & Fischer, 2009).

The roles that are assumed by the children of the alcoholics are the hero, the scapegoat, the lost child, and the mascot (Middelton-Moz & Dwinell, 2010; Zastrow & Kirst-Ashman, 2012). In 1998, Alford defined the hero as someone who would act as a parent for the whole family even for the parents. Moreover, is achievement oriented and wants things to go his way because thinks that his ways are perfect. The scapegoats are those children who are defiant not only at home, but at school too. They tend not to abide by the law and create problems for those associated with them (Black, 1992). The lost child is the one who does not socialize much and reverts to safety in the bubble of fantasy and agrees with others to avoid conflict and does not do well in academics (Zastrow & Kirst-Ashman, 2012). The mascot is the one who would act funny in difficult times to mitigate the stress in the family (Scharff, Broida, Conway, & Yue, 2004).

It was contended that those adult children who had assumed the role of the scapegoat (Aggressor in the present study) had significant more chances of being incarcerated (Werner & Broida, 1991).Similarly, those children who assumed the role of the hero were celebrated ones (Taylor, Peplau, & O’Sears, 2006).Furthermore, the researchers argue that those who assume the role of the hero are accomplishment oriented; the scapegoats are trouble makers in and outside the family and are not focused either on education and work. The children who assume the role of the lost child (in the present study the Withdrawn) are confused about their goals accomplishments and those who take on the role of the mascot are focused on doing making the family situation better (Werner & Broida, 1991). These roles have not been well studied cross-culturally (Fischer, Pidcock, Munsch, & Forthun, 2005).

The field of Health Psychology describes two types of coping. The healthy coping is also termed as constructive coping. Constructive coping includes healthy ways of dealing with the stress producing event, regardless of the outcome. Moreover, it would include dealing with the problem and realistic and rational appraisal of the stressful event and also of the abilities. It also involves recognition of the emotional reactions of the self and others and in many cases hampers disruptive behaviors (Weiten, 2013). Children’s constructive coping with the stress acts as a buffer and helps them to settle well in life (Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001) thus leads to wellbeing (Grant et al., 2003).

Weiten (2013) further maintained that the maladaptive coping is also referred as defensive coping. Defensive coping has its roots in the defense mechanisms proposed by Freud. The defense mechanisms install the process of dealing with the problem directly. Defensive coping leads to avoidance of the problem and avoidance leads to aggravated problems and is also related to the poor health. Some researchers segregate these four roles in two distinct categories (Cruse & Wegscheider, 2012) of positive and negative based on whether the roles help enhance the functionality in the family or serve to increase the already present dysfunctionality caused by alcoholism of the parental figure (Wampler et al., 2009).

Alcoholism is a stigmatized disease across the globe however, more so in a country like Pakistan where the drinking is sulked upon religiously and culturally and legally alcohol use is considered a crime (Lodhi, 2012). In spite of these restrictions, alcohol is sold unlawfully and many people are involved in its use, and thus, are prone to develop alcoholism (Zafar, 2014). Pakistan has its roots in collectivistic culture, therefore, it becomes increasingly difficult for the family when it is hard hit due to alcoholism (Samuel et al., 2014) and even more so, when the only bread winner becomes an alcoholic (Walsh, 2010).

The West offers help in multidimensional ways to the alcohol addict and the family (Osterndorf, Enright, Holter, &Klatt, 2011), for example, the Alcoholic Anonymous meetings for the alcoholics or other self-help groups for the families (Black, 2007), and more specifically for the children, for example, Adult Children of Alcoholic groups and Al-Ateen groups (Cruse & Wegscheider, 2012). Here, children or adult children who assume the family roles are taken to be in need of help, thus, help is provided to them to deal with the problems related to the roles related behaviours like rigidity (Bottke, 2008). Although, there are rehabilitation centers in Pakistan, but their focus of treatment is alcohol users and not the family (United Nations Office for Drug Control and Crime Prevention, 2003). Relatively, even in the West, this seems to be a neglected population and all the more so in a developing country like Pakistan where manufacturing, selling, possessing, or consuming alcohol is frowned upon.

The Role Identification Scale (Samuel et al., 2014) was developed in Pakistan for the identification of roles in the family with an alcoholic father. The scale has subcategories of four roles, namely the Hero, the Aggressor, the Mascot, and the Withdrawn. As per this Scale, the Hero takes responsibilities, is hard working, tries to resolve household issues, takes care of the family members, etc. The Aggressor is being cross on little things, frequently being scolded by siblings, being disobedient, etc. The Mascot is making family members happy, making others laugh, center of attention, etc. The Withdrawn is spending time alone, reading books or novels or watching TV alone, etc. Based on the content of the items and the cultural manifestations of two roles, more suitable titles were used as opposed to what appeared in the literature from the West. The two titles that were used in place of the lost child and the scapegoat were the Aggressor and the Withdrawn.

There is clearly a dearth of research on alcoholism and none with the adult children of alcoholics in Pakistan, until recently with the construction of Role Identification Scale for the Children of Alcoholics (Samuel et al., 2014).Thus, this paper focuses on the mental health of the children of the alcohol users and the roles that they assume in the family in Pakistani cultural context. It is hypothesized that more in roles of the hero and the mascot, mental health problems decrease; and more in roles of the aggressor and the withdrawn, mental health problems increase.

METHOD

In order to determine the relationship between the roles and mental health functioning it was deemed fit to use correlational research design.

Sample
The sample consisted of the adult children of alcoholic fathers who fell in the age range of 15 – 18 years (M = 21.45, SD = 2.37) and had studied upto tenth grade at least and lived in a nuclear family system. Moreover, the fathers were under treatment at the time of the study. Purposive sampling strategy was used as the focus of the study was on a highly selective population. The sample size in the current study was 400 with an equal participation of both genders.

The Table 1 represents the frequencies and percentages of all demographic characteristics. In terms of demographic variable, there is equal proportion of gender and two age groups. Most of the participants fall in Intermediate (36%) category of education, predominately having “Other” birth order and larger family size (53%).

Table 1:	Sample Distribution along Demographic Variables of the Participants (N=400)

Measures
Demographic questionnaire. The demographic form consisted of questions related to gender, age, education, birth order, and number of siblings.

Role Identification Scale. It is a self-administered measure which has 97 items developed by Samuel et al., (2014). This measure was used to assess the roles that the adult children of alcoholic fathers assume to deal with the effect of alcoholism. It is scored on a 4-point scale, 0 being not at all, 1 for rarely, 2 for to some extent, and 3 for very much. The Scale has subcategories of four roles, namely the Hero (32 items), the Aggressor (25 items), the Mascot (17 items), and the Withdrawn (23 items).The split-half reliability of RIS was .94 and test-retest reliability was .88. The concurrent validity of the scale was established by using Children’s Role Inventory (Potter & Williams, 1991) and was calculated to be .60 (Samuel et al., 2014).

General Health Questionnaire-30 (GHQ). It is a self-report measure (Goldberg & Williams, 1988). It was used to assess the mental health functioning of the adult children of alcoholic fathers on both screening and severity level. This tool could be used to screen and also to assess the severity of psychiatric disorders such as Depression, Anxiety, and Somatic Complaints. It is administered as a 4-point scale ranging from with response categories more than before, like before, worse than before, and worse than before. The inter-rater reliability of the scale is .90 and the test-retest reliability is .86. In the present study, GHQ-30 was used both to assess the risk of mental health problems and also to assess the severity of mental health problems. GHQ Comprised 30 items and all items used for severity and screening separately. Since the mental health of adult children of alcoholics had never been assessed in Pakistan, it was unknown to the researcher if there would be any mental health problems or not. Thus, it was deemed fit to use both the screening and severity indices of GHQ. Moreover, it is worth mentioning that the screening was used to get the occurrence of the mental health problem and severity was used to assess the intensity of the mental health problems.

Procedure
In order to proceed with the data collection, an appointment was set with the rehabilitation centers and followed by meeting the authorities in person. The objective of the study was explained to them and was also assured of the anonymity of the participants and confidentiality of the information. After the permission was granted the researcher met with the participants and introduced himself and shared the aim of the study, a verbal consent was taken and the participants were also informed that the participation was voluntary. Moreover, they were told that there were no wrong answers. They were to choose the answer that they thought best described them. On average it took 40 minutes to fill the forms. After the forms were filled they were checked for missing items and if there were any missing items the participants were asked to fill them up if they wanted to and if they chose not to, the forms were discarded. The forms that were complete were fed to the SPSS for the analysis.

RESULTS

The hypothesis was tested by correlating the scores of screening and severity of GHQ and four roles of Role Identification Scale. Thereafter, Hierarchical Regression Analysis was used to predict the relationship between the variables.

Table 2:	Correlation Coefficients, Means, and Standard Deviations for Screening and Severity of General Health Questionnaire and Roles of Role Identification Scale (N = 400)
**p< .01. ***p<.001

Table 2 indicates that a significant negative relationship between hero and mascot roles and GHQ scores on severity and screening. A significant positive correlation is found between aggressor and withdrawn roles and GHQ scores on severity and screening.

Hierarchical Regression: Predictors of Mental Health Functioning
The correlation analysis between the scores of screening and severity of GHQ and four roles of RIS depict an incomplete picture of the relationship between the variables. In order to get a clear picture and to accurately identify the predictors of mental health functioning of the adult children of the alcoholic fathers, hierarchical regression analysis was done. Mental health was taken as the dependent variable and the other variables were taken as the independent variables. Mental health functioning was assessed by using the GHQ on two levels, the screening and the severity. The Block I consisted of the personal demographics of the participants as control variables that is gender, age categories, education, birth order, and family size. The Block 2included the four roles assumed by the adult children of alcoholic fathers. The roles were the Hero, the Aggressor, the Mascot and the Withdrawn.

Table 3:	Hierarchical Regression Analysis Showing Predictors for Screening Mental Health Problems (N=400)

Table 4:	Hierarchical Regression Analysis Showing Predictors for Severity of Mental Health Problems (N=400)

The Table 3 and 4 indicate that in Block I, control variables hold 29% and 23% variance in screening and severity, respectively. Among these control variables on age holds significant positive prediction (β= .33, p< .001) for screening and (β = .27, p< .001) for severity. While, roles in Block II hold 65% and 66%, respectively, for screening and severity. The two roles namely the Hero and the Mascot are significant negative predictors and the other two roles, namely, the Aggressor and the Withdrawn are the significant negative predictors of mental health functioning for both screening and severity as measured through GHQ. It indicates that as one is more in role of the Hero and the Mascot, mental health problems decrease, while, in roles of the Aggressor and the Withdrawn, mental health problems increase.

DISCUSSION

The objective of the current research was to ascertain the relationship between the roles assumed by the adult children of alcoholic fathers and their mental health functioning. It was hypothesized that those participants who score higher on the roles of the Hero and the Mascot have less mental health problems as compared to those who score higher on the roles of the Aggressor and the Withdrawn.

It is plausible to indicate that although these roles appear to be opposing, yet they share a complimentary relationship with each other. It seems that the function of all of these roles is the same, for example, to mitigate the effects of alcoholism on the family; to reduce the chaos and unpredictability in the family; and to somehow restore balance of the family structure. The purpose of the roles is the same, but the approaches are varied. The adult children of alcoholics try to cope with the alcoholism in their own ways. These roles are neither good nor bad as society sometimes refers to them; they are survival strategies for the children that seem to have a price to pay. It is interesting to study the roles not in isolation, but in the context of the dynamics of the family.

The results have shown that there appears to be two clusters of psychosocial roles in the families of alcoholic fathers. The results showed a positive correlation of two roles, that is, the Aggressor and the Withdrawn with mental health issues. However, the other set of two roles, that is, the Hero and the Mascot had a negative correlation with mental health issues. The hierarchical regression analysis showed that the Aggressor and the Withdrawn were significant positive predictors of mental health problems. However, the other two roles the Hero and the Mascot were the negative predictors of mental health. These findings are in agreement with previous researches (Fisher & Wampler, 1994; Potter & Williams, 1991; Wampler et al., 2009; Young & Adamec, 2013). These findings can be explained in the light of a study done by Werner and Broida (1991) that those adult children of alcoholics who assume the role of the Scapegoat or the Lost Child were more likely to be incarcerated and those children who play the role of the Hero would more likely to be employed in large corporations, thus, leading to the functionality or dysfunctionality in the family. In the present study, roles of the Aggressor and the Withdrawn lead to more mental health problems. When individuals have more mental health problems than one could reason that they would get more involved in risk taking behavior such as breaking the law and then be caught and incarcerated.

It is quite possible that the adult children, who were more in the roles of the Hero and the Mascot were trying to cope with the father’ alcoholism through assuming responsibility to reduce the stress and strain in the family, thereby, leading to acceptance in the family and also internally satisfying them, thus, having better mental health. On the contrary the adult children who assumed the roles of the Aggressor and the Withdrawn dealt with the family situation of having an alcoholic parent by either opting out or manifesting belligerent behavior, thus leading to destructive style of coping. Such roles lead to the enhanced stress and strain in the family. These roles may have led to less acceptance from the family, thus leading to mental health issues (Compas et al., 2001; Grant et al., 2003).

In control variable, age had significant role that is, with increase in age mental health problems were increasing. This could be accounted to the progression of alcoholism and dysfunctionality within the family (Jay & Jay, 2000; Young & Adamec, 2013).

Although, it is surprising that the study was conducted in a different culture yet the results have been similar. The similarity of the results across cultures could plausibility be attributed to the possibility that the family dynamics in the family of an alcoholic parent are the same across culture, thus, leading to similar behaviors on part of the children that later turn into roles. However, more research in this area should be conducted.

CONCLUSION

This paper highlights a very pertinent problem that is faced by the society. Although, drinking alcohol is prohibited in Pakistan yet people drink and many fall prey to alcoholism. It is not only the alcohol user that suffers, but also the family. There have been very few studies on the adult children of alcoholics. The children of alcoholics cope with the father’s alcoholism by assuming certain roles. This study has established a relationship between the roles that the children assume and their mental health functioning. The results were similar to the literature from the Western world, which emphasizes the point that the family chaos and unpredictability in the family of alcoholics have similar family dynamics across cultures. Thus, possibly leading to similar pressures and expectations, therefore, leading to the same kind of mental health issues and coping in the form of the roles assumed. This study would act as an impetus for similar studies to establish a knowledge bank for such topics in Pakistan.

IMPLICATIONS

The findings of this research have clinical and research-oriented value. In Pakistan, the young or adult children of alcohol users have never been the focus of attention for the mental health professionals. Moreover, they have not been even regarded as a vulnerable population in the need of attention. The results would further help the mental health professionals working in the field to understand the dynamics of the family that would help them develop effective treatment program encompassing the whole family.

SUGGESTIONS FOR FUTURE RESEARCH

In order to deal with the limitations, some suggestions are made for future studies. The data were collected from the private rehabilitation centers; it would be interesting to collect data from government run facilities and also from rural cities and villages to have a comparison. The role of the mother (spouse of alcohol user) was not assessed, in future research, it would be helpful to incorporate studying the mother’s role as well to understand the dynamics of the family in a comprehensive manner. Moreover, it would be interesting to replicate the present study and extend it to the families of people suffering from other chronic diseases such as arthritis or schizophrenia and determine whether or not the children develop any roles as measured by using Role Identification Scale. In the present study, GHQ was used to assess the mental health functioning of the adult children of alcoholic users. For future reference, it would be better to use specific diagnostic tests related to depression or anxiety, etc. Furthermore, it will be helpful to use semantic differential to determine how the adult children with the roles perceive each other. Studying each role independently would help understand the dynamics of each role in a better way. All of the above mentioned suggestions would help in understanding the families as a whole and also the individuals in the family. Moreover, with better understanding prediction would be easier and different intervention programs could be devised and employed to help those suffering in silence.

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