Drug Addiction

THE DRAMA of drug addiction is obvious. It fills the stage with violence, stealing, arrests, intense emotional highs, periods of des-perate craving, and possible death from overdose. Less obvious, however, is the stability that actually underlies these fluctuations—a stability that includes both the addict and his family. These phenom-ena are stable in their predictability, their repetitiveness, and in the function they serve for the people involved. This chapter is an attempt to identify some of the elements within the process and integrate them into a conceptual model.

Our plan is to lead the reader through the evolution of some ideas that have emerged from our observations and research, and to integrate these, whenever possible, with the work of other investi-gators. The focus will be on a class of factors that have not always been considered in the drug-abuse field and appear to be quite potent, especially as they relate to the maintenance of addiction. We wish to emphasize that, although we are applying a particular framework to compulsive drug use, we are not denying the importance of physio-logical variables in addiction; we recognize that a drug can be ex-tremely powerful in its own right. It is also accepted that—in addition to the family—economic, environmental, and conditioning determi-nants are also crucial.

This chapter is a revision of a paper by the authors entitled "Heroin Addiction as a Family Phenomenon: A New Conceptual Model- and is reprinted with per-mission from the American Journal of Drug and Alcohol Abuse, 1978, 5, 125-150. 0 Marcel Dekker, Inc.

Appreciation is extended to Jim Mintz, PhD, Salvador Minuchin, MD, Braulio Montalvo, MA, and Bernice I.. Rosman, PhD, for their helpful comments on an earlier version of this chapter.

RESEARCH ON ADDICTS' FAMILIES

Drug abuse generally has its origins in adolescence. It is tied to the normal, albeit troublesome, process of growing up, experimenting with new behaviors, becoming self-assertive, developing close (usually heterosexual) relationships with people outside the family, and leav-ing home. Kandel et al.,76 extrapolating from their data, propose that there are three stages in adolescent drug use and each has different concomitants. The first is the use of legal drugs, such as alcohol, and is mainly a social phenomenon. The second involves use of marijuana and is 'also primarily peer-influenced. The third stage, frequent use of other illegal drugs, appears contingent more on the quality of parent-adolescent relationships than on other factors. Thus, it is concluded that more serious drug abuse is predominantly a family phenomenon, which corresponds to the conclusion by Blum et al." that the peer group has little or no influence as long as the family remains strong.

At least five literature reviews have been published that deal with family factors in drug addiction.n7. 8". "7 "I• ''" These reviews describe a prototypic pattern for male addicts' families in which the mother is involved in an indulgent, enmeshed, overprotective, overly permissive relationship with the addict, who is put in the position of a favored child. Often he is -spoiled.-P's He is reported by the mother

to have been the -easiest to raise- of the children and was generally good- as a child.s1 L') Fathers of male addicts are reported to be detached, uninvolved, weak, or absent.* Compared with normals, the father-son relationships in addicts' families are described by the addict as being quite negative, with harsh and inconsistent discipline, especially for those who inject heroin versus those who inhale it.'t•"'"

A disproportionate number of fathers are reported to have a drinking problem."^3,58.105,                 ""' 179'1"St Schwartzman' 3" describes two types of addict fathers, a -straw man- type who is authoritarian, violent, but easily controlled by mother, and a distant type who is clearly secondary to mother in terms of power within the family. Interestingly,

*As noted in Chapter 6, caution should be exercised regarding these conclusions, as Kaufman and Kaufmann" noted enmeshed father-child relationships in 40%, of their cases—particularly within certain ethnic groups. Further, Alexander and Dibb2 feel the father (rather than the mother) assumes the overinvolved role in some middle-class families, a pattern we also found in approximately 5% of the Addicts and Families Program (AFP) families.

10f course the statistical distributions in these and other studies cited in this section are overlapping (e.g., some -normal" families vvill also show such patterns).

Rosenberg123 reports that siblings of male addicts are more likely to have a positive relationship with the father. In contrast to males, female addicts seem to be in overt competition with their mothers (whom they see as overprotective and authoritarian), while their fathers have been reported to be inept, indulgent of them, sexually aggressive, and often alcoholic; the probability of incest is much greater than normal:6.'4, '9" with estimates running as high as 90%.'8 A high incidence of parental deprivation is reported for families of both sexes, many of whom have experienced separation or death of a

parent—most commonly father—before age 16.', li,67,80 /,,12(.182 How_

ever, this incidence appears to be changing in recent years, so that rates in addicts' families are now more comparable to the overall population.'51 In general, research in this area has progressed from reports by the user about his family, to dyadic (e.g., mother-child) assessments, to triadic (parents and child) concepts, and, with the more sophisticated studies, to assessments of the interactional behavior of the whole family. 

ADDICT FAMILY CONTACT

One area that has tended to be overlooked or unrecognized in the drug-abuse field is the extent to which -hard- drug users are involved and in contact with the people who raised them. For adolescents such involvement is natural and developmentally appropriate, since they are still minors and are generally not expected to have left home. On the other hand, it is not necessarily obvious that addicts in their late 20s and early 30s would still be involved with their families of origin. Their age, submersion in the drug subculture, frequent changes in residence, possible military service, and so forth, would seem to imply that they are cut off, or at least distanced, from one or both parents.

On the other hand, there is a preponde

rance of evidence (pre-sented in Appendix A) that, despite their protestations of indepen-dence, the majority of addicts maintain close family ties. Even if they do not reside with their parents, they may live nearby, and their frequency of contact is much higher than that occurring among comparable -normals,- other psychiatric patient groups, or even polydrug abusers. Fifteen of 17 reports on living arrangements, and 7 of 7 reports on frequency of family contact attest to this pattern (these studies are reviewed in Appendix A). For example, Perzel and Lamon"3 found that 64%, of heroin addicts were in daily telephone contact with at least one parent, compared to 51% of polydrug

abusers and 9% of normals. Further, this appears to be an inter-national phenomenon, as similar rates of addicts living with parents have been found in Puerto Rico, Italy, England, and Thailand, in addition to North America. In sum, it would appear that at least two-thirds of male hard drug users under age 35 live with the people that raised them and 80-85% are in at least weekly contact with these same parental figures. In fact, we have observed these intense en-tanglements so often in our clinical work that we are by now skeptical when any addict tells us that he does not see his parents regularly. We tend to regard such responses as moves to protect the family rather than as valid in their own right (see Chapters 4 and 5 ).

Of course, either living with parents or seeing them regularly is not necessarily' an indication of dysfunction. Depending on the cul-tural and ethnic milieu, such arrangements can be quite natural, and maintaining regular family involvement certainly does not mean one will become a drug addict. What may be more important is the quality and the operational—functional structure within families who develop drug-abusing offspring, with consideration also given to their stage in the family life cycle. Overinvolvement, then, can only be considered an indirect measure of family dysfunction. However, there is some evidence that it can have meaning and value in terms of determining both the prognosis for existent treatment paradigms and the direc-tion for new therapeutic modes. For example, Vaillant182 found that addicts who became abstinent did not live with their parents, and Zahn and Ball's '96 data indicate that cure was associated with not living with parents or relatives. Both reports noted a correlation between living in the home of relatives and continued addiction. Further, in a comparison of posttreatment outcomes by Stanton et significant correlations were found between regularity of con-tact with a parent and the extent of use of illegal drugs (.20), as well as use of marijuana (.23); the correlations were similar when mea-sured against whether the addict lived with his parents (all illegal drugs, .21; marijuana, .22). These results imply that being closely involved with one's family of origin is not necessarily healthy, especially among young men aged 20 to 35

DUNCAN STANTON - THOMAS C. TODD