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Let us consider why hospital patients receiving regular dosages of a narcotic at higher-than-street-level concentrations rarely report noting a withdrawal response when they return home and cease their use of the drug (Zinberg 1974a). As long as individuals feel they can deal with their lives, do not think of themselves as addicts, and reenter an environment which does not acknowledge withdrawal and provides strong alternate gratifications, they will not experience debilitating withdrawal. ln the case of the hospital patient, we see that a setting may temporarily produce a level of discomfort which is comparable to that which the addicted drug user experiences regularly. Like the addicted user, the patient may rely on drugs in the hospital. When the patient leaves the hospital and the discomfort behind, however, and reengages in meaningful activities, the drug experience loses its usefulness.

The field research which illuminates most clearly the role of setting in addiction is that surrounding the Vietnam soldier. ln Vietnam, facing stress, discomfort, danger, lack of social support, and the absence of opportunities for constructive effort, many men resorted to narcotic use. More drastically, of those men who were found to be using a narcotic in Vietnam, 75 percent reported they were addicted in that setting. A followup study found that one-third of the drug users continued to use a narcotic when back in the United States. Yet the researchers found that only nine percent of the Vietnam addicted group showed signs of addiction at home (Robins et al. 1974a). These data show how setting determines whether drug use will be addictive or not even when amount and type of drug use remain constant. For in Vietnam, circumstances modified the appeal of the analgesic experience for the individual and the need he had for that experience.

COMPLEXITIES IN ADDICTION

Utilizing the experience produced by a drug as the central element in the definition of addiction does not obviate the role of a drug's pharmacological effects. Powerful psychoactive drugs are obviously the substances which are most directly capable of producing the experience to which an individual may become addicted (although they are not the only causes of such experiences). The nature of a drug's effects is a determinant of the type of experience a user will have, and users may have genuine preferences for different classes of drugs depending on the function they seek a drug experience to provide. Thus, while depressant drugs (those which create analgesic effects), such as the barbiturates, the narcotics, and alcohol, are major objects for drug addiction, stimulant drugs are another class of drugs with addictive potential. For example, laboratory research now indicates that it is not possible to distinguish qualitatively between the withdrawal produced by stimulant drugs, such as caffeine, and narcotic withdrawal (Goldstein and Kaiser 1969). The mechanism of addiction in the case of the stimulant experience is the absorption of the user's attention by the arousal state the drug leads to. This internal stimulation, it seems, makes the drug user less aware of the external stimuli which create tension. Cigarette smokers have been shown to be more tense than nonsmokers but to experience a reduction in tension from smoking that nonsmokers do not report (Nesbitt 1972). ln this paradoxical way, a stimulant can create an analgesic effect for certain individuals.

ln smoking, as in all addiction, the experience consists of elements in addition to the drug's effects. The chief of these is the ritual associated with the drug use. A substantial portion of heroin addicts will have their withdrawal suppressed simply by undergoing the ritual of injection, without receiving any of the drug (Light and Torrance 1929). Similarly, cigarette smokers will not respond totally to nicotine which is not taken in through inhalation, even if the alternate method for consuming the drug is more efficient (Jarvik 1973). We can understand these phenomena when we note that with both stimulants and depressants, it is primarily the overall reassurance of the drug experience to which the addict is responding. Predictable and habitual aspects of the setting in which the drug is consumed will be as much a part of the addiction as the substance itself.

Addiction to a given drug is not constant from culture to culture. For example, debilitating alcoholism is almost unknown in certain rural Mediterranean societies (Blum and Blum 1969). The evidence is that a culture's attitudes toward a drug influence whether or not the drug will be abused. ln particular, societies which have high alcoholism rates are those in which a premium is placed on power but in which it is difficult for one to achieve power. ln this cultural context, alcohol intoxication leads to fantasies of personal domination over other people (McClelland et al. 1972). Behaviors which occur in line with this drinking are fighting, crime, reckless driving, and other aggressive and antisocial acts. Compare this to the kind of drinking which occurs in a Greek cafe, where the disinhibition that alcohol produces is used to enhance social conviviality. Not only does the social meaning of alcohol change, but the very processes of thought and feeling which it sets off in the individual can be seen to vary.

Placing the power-oriented drinking syndrome in the addiction cycle, we find that individuals who doubt their efficacy drink in order to gain the illusion of power. Attempts to dominate others while drunk, however, actually lower social standing and contribute to a sense of futility and low self-esteem. Drinking may become the one avenue to a satisfactory—if temporary—self-image, and drunkenness becomes a preferred state. ln a culture where intoxication does not produce these feelings and is not taken as an excuse for antisocial behavior, the drinking experience is not one which can serve as the object of an addiction.

SPECIAL POPULATIONS

Doctors as a group have often been singled out for their high incidence of narcotic and other drug use. While many physicians do suffer debilitating effects from their involvement with a drug, there are also indications that many physicians use narcotics for long periods of time without showing such negative effects (Winick 1961a). There are several factors which might make it less likely for narcotic use among doctors to reach an uncontrolled stage. These include the status of their position, the meaningfulness of their work, the self-control required in their training and certification, and so on. Medical doctors, therefore, have come to provide some of the best examples of controlled use of narcotics.

Recent research has modified this picture in important ways. While doctors obviously have advantages in hiding—and even controlling— their drug involvements, it is now clear that such controlled use is far from exceptional. lnvestigations among both middle-class users and ghetto residents using narcotics indicate that the percentage of controlled users is high and that these populations do not differ significantly from medical doctors in this respect (Lukoff and Brook 1974). This special population that has been uncovered is not defined by occupation, by economic or social status, or by other demographic factors. lt is the group of people who are able to subjugate their drug use to other aspects of a productive life. The factors that have been shown to enable a person to do this include a sense of purpose or mission that dictates times when drug use is not appropriate, sets of friends who are not involved in use of the drug, and models for controlled use either among peers, status figures, or family (Jacobson and Zinberg 1975).

A Family Theory of
Drug Abuse

M. Duncan Stanton, Ph.D.

THEORETICAL CONSIDERATIONS

ln developing a theory of drug abuse, my colleagues' and l were faced with explaining several phenomena in the behavior of drug abusers which were not accounted for by existent theories. One of these is the repetitive, recurrent nature of addiction; related to this is the high incidence of treatment dropouts. We were also dissatisfied with the static theories which predominated in the field—theories which took little or no cognizance of (a) the ongoing behavior in its context, (b) changes and/or repetitive patterns which occurred during a given time period, and (c) the interpersonal and contextual functions of drug abuse (Stanton 1978b). Before proceeding to discussion of a theoretical model, however, there are several conceptual considerations, stemming from these observations, which need further elucidation.

SYMPTOM CONTEXT

A major concern which, again, has too often been overlooked in the drug abuse field pertains to the context of the symptom as this relates to its genesis and its maintenance. There is a need for viable theoretical models which take into account both the actual symptomatic behavior and the behavior of others within the symptom-bearer's interpersonal system. Symptoms generally do not just "pop up." They occur within a context, and most would agree that they serve functions within this context—both for the symptom-bearer and for the other people involved.

1 Many of the ideas presented here were developed through a collaborative effort with a number of colleagues, including Thomas C. Todd, Ph.D.; David B. Heard, Ph.D.; Sam Kirschner, Ph.D.; Jerry l. Kleiman, Ph.D.; David T. Mowatt, Ed.D.; Paul Riley; Samuel M. Scott; and John M. VanDeusen, M.A.C. Jay Haley, M.A., also provided important input. A major result of this collaboration has been the conceptual paper by Stanton et al. (1978).

ln fact, some of these others (e.g., family members) may actually have an investment in maintaining the symptom. Consequently, our formulations need to encompass the total "gestalt" of (a) the symptom, (b) the treatment, (c) those affected by the treatment, and (d) the effects these last also have back on the treatment endeavor. This is, then, a cyclical process, involving numerous homeostatic and feedback mechanisms. On this point, Nathan and Lansky (1978), in a recent review of the problems in research on the addictions, have stated, "A frequently ignored issue ... is that a treatment program may be highly effective in attaining desired goals while patients are actively involved in the program, only to appear to fail when patients return to nonsupportive or destructive environments" (p. 82). lt is inclusion of these "nonsupportive" and "destructive" influences which is being stressed here. Treatment does not take place in a vacuum, and if the external variables which impinge before, during, and after treatment are not changed, or at least evaluated, both treatment and investigatory efforts operate at a considerable disadvantage.

NONLlNEAR CAUSALlTY

ln some ways we are addressing the issue of causality here. Much research in the drug abuse field has not enjoyed the luxury of having comprehensive causal models to give direction to its efforts. An important issue surrounding the problem of causality pertains to its linear versus its nonlinear nature. For instance, if one were to regard causality from a linear standpoint, one would assume that A causes B, or that A and B cause C. A nonlinear, or open systems model, on the other hand, would more likely portray the process as a sequence: A leads to B, B leads to C, and C leads back to A. The behaviors of the involved individuals or human systems are sequential and cyclical. We would thus want to look at the components, elements, and specific behaviors which constitute the cycle. The addiction/readdiction pattern is an example of just such a process. Nonlinear causality, while requiring a different approach to the ways in which we think about symptoms such as drug abuse, holds considerable potential for explaining the addiction process. However, from an operational standpoint, it also requires a revision of many of the dependent and independent variables to be examined.

FAMlLY LlFE CYCLE

lt is helpful to view any family in terms of its place in the family developmental life cycle. Most families encounter a number of similar stages as they progress through life, such as birth of first child, child first attending school, children leaving home, death of a parent or spouse, etc. These are crisis points, which, although sometimes difficult to get through, are usually weathered without inordinate difficulty. On the other hand, symptomatic families develop problems because they are not able to adjust to the transition. They become "stuck" at a particular point or stage. Like a broken record, they repetitively go through the process without advancing beyond it (Haley 1973). This process as it applies to drug users will be discussed below.

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