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
