Siblings PSU impacted various aspects of family life and changed their relationships and the family systems. Based in general system theory, a family system can be understood as being unique, with their own rules and decision-making processes that distinguish them from all other systems (von Bertalanffy, 1950). Over time, well-functioning family systems thus develop patterns of interaction that allow the family life to work and appear stable. For example, if one member of the family is in trouble, somebody ‘doubles’ for them and fills their role as best they can (Messer, 1971, p. 380). When a major change impacts family life the balance of the family is knocked off kilter. This understanding is grounded in family systems theory and the two hypotheses that make it up: (1) the family is an autonomous system and (2) the family is an adaptable system (Priest, 2021). In this context “autonomous” mean the processes that serve to generate and maintain the family system. Adaptable system’ means that any system has to be able to adjust to ongoing changes to exist. In response to changes within the system, families thus need to react. However, families end up facing issues when those processes become either too rigid or too adaptable, or when so much pressure is put on one of the two processes, that the system eventually ends up being overwhelmed (Priest, 2021). The participants in the study described how the demanding circumstances meant that they were forced to make major changes. To survive as a family, they had no choice but to adapt. However, the challenges relating to the PSU meant that the changes that occurred regarding the roles and relationships of each family member happened to such an extent and at such a pace the family system was not prepared for. Thus, based on family systems theory (Priest, 2021, p. 10), too much of the responsibility for keeping their family’s autonomy was put on needing to adapt. This brought about a ‘role reversal’ (Mayseless et al., 2004). Even though the participants who took part in the study were young adults or adults, all of them could be considered as family members who had been forced to take on major care-giving roles ‘overnight’, that they hadn’t been prepared for.

Role reversal affects patterns of communication, but is not necessarily negative, and it usually becomes necessary through changes and adjustments in the roles within the family over the course of a life cycle (McGoldrich et al., 2014). For instance, evident in the young adult trying to distinguish themselves from their original family unit and developing adult-to-adult relationships with the parents is an important part of one’s life cycle (Carr, 2012). Role reversal can be a turning point in the development of a family’s resilience, as it can help increase the family’s capacity to adapt when dealing with a particularly stressful situation. However, for many families, these changes happen so fast and were of such a serious nature that the family system was then negatively impacted. Titlestad et al., (2020a, 2020b) describe how DRD-bereaved parents had often, for a long time, taken over the responsibilities which would normally, depending on the child’s age, have been handled by the child themselves. Other scholars refer to this tendency as ‘extended parenthood’ (Tysnes & Kiik, 2019), which reflects the consequences that this extension of duties often have for parents of children who need this continued support (Titlestad et al., 2020a, 2020b). Extended parenthood for one of the adult children in the family affects siblings' relationship with their parents in a long-term perspective and combined with a role reversal, it may mean long-term repercussions for the family system and siblings’ position. The different information family members had then made it difficult for the family members to deal with the challenges with a common understanding. So instead of having a unified plan to try and solve and tackle the challenges head on, almost everyone would end up having to take their own measures.

The participants’ experiences of these measures they set in motion themselves, or were given responsibility for, were extensive and described as having impacted them on both a personal and relational level. This aligns with much of the previous research (Gabriel, 2017; Tsamparli & Frrokaj, 2016). To protect themselves, they had to try and shield themselves for periods of time, for example, by moving further away, not picking up the phone, not meeting up with their sibling. Many of the participants expressed this as being necessary, but that it also gave them a troubled conscience. The participants therefore found themselves in a double-bind situation, as each choice had negative consequences: for themselves, for their sibling, or for other members of the family (Bateson, 1972).

Having a sibling with PSU is a stressful situation, both physically and psychologically and makes everyday situations hard to cope. People living in demanding and stressful life situations can, however, still experience their lives as being positive. This also applied to the participants in our study. On that occasion, salutogenesis is relevant. Salutogenesis is the focus of looking at the resources available to a person, Berg et al., (1996). Finding out what it is that helped the siblings live with the stress and challenges of PSU in the family are key issues we must research when it comes to figuring out how to cope and deal with the situation. As a response to this salutogenic question, Antonovsky developed the concept sense of coherence (SOC). The concept consists of three factors that, when combined, can help provide a high level of SOC. The three factors include: comprehensibility, manageability, and meaningfulness. With these, Antonovsky claimed that a SOC can help us better deal with the stressors in our lives (Thybo, 2004). A high attainment of SOC is thought to provide an individual with stability when forced to face stressful situations. The theory describes all the fundamental factors required to master one’s stress in any context (Berg et al., 1996; Ekblad & Wennström, 1997).

Comprehensibility ensures that the strain and stress one is put under in any given situation is cognitively understandable, sequential, and coherent. The individual must therefore be able to understand what they are being exposed to, in a way that makes the world appear rational and predictable (Antonovsky, 2000). If we transfer this comprehensibility to the siblings’ experiences of living in a family with a substance-using brother or sister, this could, for instance, include the siblings seeking out more knowledge about PSU, as well as being there for suffering family members. Psychoeducation is often used when working with relatives in this kind of situation, through the employment of professional help, such as family therapists, or through disseminating research-based knowledge on what it means to be a relative of someone with PSU. Psychoeducation can thus expand one’s opportunities to act in such an arduous situation, as it could provide an enhanced insight into, and new perspectives of the situation (Christiansen, 2015).

Manageability—can be understood as the feeling that the resources the individual has at their disposal are adequate to cover their needs and are the right resources to use in this particularly stressful situation (Antonovsky, 2000; Ekblad & Wennström, 1997; Thybo, 2004). Resources can be seen as specific, physical resources that can be externally sourced too, such as other people who can help. Many of the siblings in the study had spent a lot of time and energy coming to terms with the services they could use, to find the right organisation that could help their brother or sister with whatever they needed, from financial aid to treatment. Resources relating to the siblings’ own functionality and life situations were also mentioned by several of the participants as being vital when it came to negotiating their demanding family situation.

Antonovsky (2000) describes meaningfulness as the individual’s experience that it is worth investing energy in trying to solve the challenges they are dealing with. In this context, then, a sense of coherence can be understood as central to the development and maintenance of the family’s resilience, as it contributes to both strengthening the family unit, as well as the individual family members’ perseverance and abilities to master the ongoing stressful life situation. Thus, the concept of family resilience is especially timely, as our world continues to grow increasingly more complex and unpredictable, with families now facing unprecedented challenges (Walsh, 1996). Or, as Participant 3 put it: ‘I helped him because he was my brother, and because I loved him’.

Patterson et al. have conducted several studies about families living with different long-term, chronic illnesses (Patterson & Garwick, 1994). The researchers claim that a family’s adjustment to long-term stress is a process that evolves over time, during which meaning, behaviours, and emotions all reciprocally influence one another in the social context of the specific family (Patterson & Garwick, 1994). New routines and roles are needed to be able to manage the tasks related to dealing with the illness, and the family’s former, structural organisation may no longer be enough to meet the new challenges (Patterson, 1988). How the family restructures itself as it adjusts to the demands the illness has placed on their lives may impact the identity of the family and their overall sense of purpose in life. For some families, this may mean that the focus of their resources is channelled into dealing with the illness, such that other needs in the family are given less space (Patterson & Garwick, 1994).

Patterson and Garwick (1994) point out that understanding this family adaptation in relation to long-term family struggles involves paying more attention to their meaning-making process. Family members’ understanding of the reasons and consequences of said illness often sets a course as to how the family will respond as time goes on. According to the authors, working with families to develop shared situational meanings—that reduce guilt and blame and include shared responsibility for managing the condition—can be perceived as an adaptive response (Patterson & Garwick, 1994, p. 297).

The findings of this study can be seen as a contribution to more knowledge about the major strains put on family life after a DRD, particularly for those who have lost their sibling as a result. Well-functioning family systems are flexible and capable of dealing with change well. PSU, however, may be of such a nature that the changes that those problems force into existence are more severe and happen at a much faster rate than what most family systems will be able to cope with, without their having to deal with major personal and relational challenges. Any relevant measures that can be taken to help should therefore not overestimate the strengths of the family system, specifically when faced with such extensive challenges. Petterson and Garwick pointed out as early as 1994 that one way in which practitioners can facilitate better family adaptation to a chronic illness is to pay more attention to the family’s meaning-making process and to support families in making these processes more explicit and more adaptive. The value of people talking about their experiences to each other and to the attentive listening professionals is highlighted in several central systemic ways of working (Lorås & Ness, 2019; Lorås et al., 2017). To facilitate family conversations, practitioners need basic and central systemic psychotherapy knowledge and skills, which give a structure to the conversations in which several persons and perspectives are presented, and with a central systemic focus on understanding psychological difficulties in the context of social relationships and culture (Boston, 2000).

It is therefore essential that professionals have this understanding of the family’s long term-perspectives and the consequences for the siblings in particular, both while their siblings are still alive and after they have died. However, several earlier studies (Adams, 2008; Copello et al., 2010; Selseng & Ulvik, 2019) also reported how the dominant trends in substance-use policies provide limited opportunities to implement any integrated work with families. This study, on the other hand, clearly shows how important it is to offer families the opportunity to enter joint conversations so that they can receive the help and support they need for the ongoing challenges they are subjected to, and to prevent a breakdown of the family unit in the future.

As qualitative researchers, we acknowledge that the analysis process used in this study draws heavily on the researcher’s ability to be critically aware of our own ‘built in’ assumptions and preconceptions, as well as the participants’ cultures. We have strived to be transparent and rigorous in our work by presenting each step of the analysis and showing examples of the participants’ quotations. A purposefully designed sampled group of participants shared their experience of family relations prior to their siblings’ deaths. The time that had passed since the loss of their siblings varied from three to 360 months. Thus, their memories of the time before their siblings’ death differed greatly. A potential strength of this is that the participants have had enough ‘distance’ from their families’ struggles prior to their siblings’ deaths to talk about the situation openly. Perspective for life experiences is probably different when siblings look at it with distance to ongoing overload, they earlier experienced, but precisely because of the distance, it can also give more and other nuances to siblings’ life situation. However, this can also be seen as a limitation, as it was such a long time ago since they had this experience, that they may now only remember certain aspects. A possible limitation is also that it is often possible that participation in this type of study appeals especially to those participants who are particularly engaged and involved, and, thus, for example, do not present the experiences to those siblings who have distanced themselves early or who took on different roles within the family.