Family and Key-Informant Perspectives on Relational Dynamics in Iranian Families Affected by Substance Use Disorders: A Reflexive Thematic Analysis with Codependency-Informed Insights

Abstract

Background: Family distress related to substance use disorders (SUDs) can be examined through the concept of codependency; however, this construct remains conceptually inconsistent and underexplored in non-Western settings. In this study, codependency was conceptualized as a relational lens for understanding overinvolvement, emotional enmeshment, and enabling behaviors rather than as a discrete diagnosis. Objectives: To explore the lived experiences of Iranian wives and parents of individuals with SUDs and to contextualize these experiences within the perspectives of addiction professionals with experience in this field. Methods: This multi-perspective qualitative study used purposive sampling to recruit 20 family members (9 wives, 7 mothers, and 4 fathers) from outpatient addiction treatment settings and 10 key informants (psychologists, psychiatrists, social workers, addiction specialists, and Narcotics Anonymous members) in Tehran and Isfahan, Iran. Semi-structured interviews were conducted between September 2023 and April 2024, audio-recorded, and transcribed verbatim, and the data were analyzed using reflexive thematic analysis supported by ATLAS.ti 23. The findings were subsequently synthesized at the interpretive level to assess convergence, complementarity, and divergence between the two data sources. Results: Five interrelated themes were identified from family narratives: 1) control, distrust, and surveillance; 2) self-sacrifice and loss of self; 3) emotional entanglement and fear of abandonment; 4) enabling and reality avoidance; and 5) psychological distress and low self-worth. Across interviews, these patterns were embedded in strong family interdependence, gendered caregiving expectations, and honor- and shame-related stigma. Key informants additionally emphasized rigid family hierarchies, “addiction to the addict,” unconscious recovery sabotage, and martyrdom dynamics. Integrating both perspectives underscored how cultural scripts surrounding honor and shame actively shaped enabling and concealment behaviors. Conclusions: Within this urban, treatment-seeking sample, family relational dynamics surrounding SUDs were understood in relation to chronic psychological distress and culturally embedded expectations regarding caregiving, honor preservation, and stigma avoidance. Routine family assessment and culturally responsive, family-based interventions addressing control, enmeshment, enabling, and psychological distress may help meet the needs of both people with SUDs and their relatives. Future research should develop and test culturally adapted family interventions in collectivist contexts.