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DRUG ABUSE AS A FAMILY PHENOMENON
While the emphasis here will be on opiate users under the age of 35, it is my experience and that of my colleagues that most of the patterns and processes described apply to people and families who indulge in heavy, compulsive use of other drugs as well. A number of features will be presented, leading to a family homeostatic model of addiction. Only certain of the pertinent references will be cited, and the reader is referred to Stanton (1978a, 1979b, 1980) and Stanton et al. (1978) for more complete documentation.
Accumulating data indicate that a high percentage of drug abusers' families have experienced premature loss or separation during the family's life cycle. The relationship between drug addiction and
(a) immigration or (b) parent-child cultural disparity appears to be important. Alexander and Dibb (1975) and Vaillant (1966b) discovered that the rate of addiction for offspring of people who immigrated either from another country or from a different section of the United States was considerably higher (three times so for Vaillant's sample) than the rate for the immigrants themselves. ln addition, Vaillant found that offspring of immigrants who were born in New York City were at greater risk for addiction than either their parents or offspring born in the former culture. Noting the abnormal dependence of addict mothers on their children, he suggested that (a) immigrant parents are under the additional strain of having to cope with their new environment,
(b) parental migration may be correlated with parental instability, and
(c) "the immigrant mother, separated as she often is from her own family ties, may be less able to meet the needs of those dependent on her and yet experience greater than average difficulty in permitting her child mature independence" (p. 538). lt might be added that immigrant parents are also faced both with the "loss" of the family they left in their original culture and their own possible feelings of guilt or disloyalty for having deserted these other members. ln any case, what appears to happen is that many immigrant parents tend to depend on their children for emotional and other kinds of support, clinging to them and becoming terrified when the offspring reach adolescence and start to individuate.
With non-immigrant families of drug abusers, a high proportion show traumatic, untimely, or unexpected loss of a family member, experiencing more such early deaths or tragic losses than would be actuarially expected (Coleman and Stanton 1978). This has led to the idea that the high rate of death, suicide, and self-destruction among addicts is actually a family phenomenon in which the addict's role is to die, or to come close to death, as part of the family's attempt to work through the trauma of the loss; in a sense, addicts are sacrificial and rather noble figures who martyr themselves for the sake of their families (Reilly 1976; Stanton 1977b; Stanton and Coleman 1979).
FEAR OF SEPARATlON
Related to this discussion is the intense fear of separation that these families show (Stanton et al. 1978). For instance, addicts do not function well because they are too dependent and not ready to assume
responsibility—as if they want to be taken care of. They fear being separate or separated. However, closer observation of the whole family generally reveals that when addicts begin to succeed—whether on the job, in a treatment program, or elsewhere—they are, in a sense, heading toward leaving the family, either directly or by developing more autonomy in general. At this point, some sort of crisis almost inevitably occurs in the family. On the heels of this the addict reverts to some kind of failure behavior and the family problem dissipates. The implication is that not only does the addict fear separation from the family, but that the reverse is also true. lt is an interdependent process in which failure serves a protective function of maintaining family closeness. The family's need for the addict is greater than or equal to the addict's need for them, and they cling to each other for confirmation or, perhaps, a sense of "completeness" or "worth."
Some corroboration of the notion that addicts are tied into their families of origin can be obtained simply by observing how often they contact their parent(s). This is a facet of the drug abuser's lifestyle which has generally been overlooked, since it is not obvious that addicts in their late twenties and early thirties would still be so involved; their age, submersion in the drug subculture, frequent changes in residence, possible military service, etc., all seem to imply that they are cut off, or at least distanced, from one or both parents. However, despite protestations of independence, there is increasing evidence that most addicts maintain close family ties. Stanton (1980) has accumulated 14 sources which deal with this idea, and all but one (a poorly designed study, it should be noted) support the close-contact hypothesis. For instance, our own data (Stanton et al. 1978) from an anonymous survey of 85 heroin addicts (average age, 28) showed that 66 percent either resided with their parents or saw their mothers daily, while 82 percent saw at least one parent weekly. Further, similar patterns have emerged in ltaly and Thailand, where 80 percent of addicts live with their parents. More recently, Mintz2 is gathering data in Los Angeles which appear, at this point, to duplicate the above results, and Perzel and Lamon (1979) have identified a similar pattern with polydrug abusers, also finding that the frequency of family-of-origin contact for the abusers was five times that reported for a comparison group of nondrug users. ln sum, the accumulating evidence has tended to yield data consistent with a close addict-family tie hypothesis.
The studies supporting the conclusions in this section are too numerous to cite here, and the reader is referred to reviews by the author (Stanton 1979b,c, 1980) for further documentation. The prototypic drug abuser's family—as described in most of the literature—is one in which one parent is intensely involved with the abuser, while the other is more punitive, distant, and/or absent. Usually the overinvolved, indulgent, overprotective parent is of the opposite sex from
2 J. Mintz, University of California, Los Angeles, and Brentwood VA Hospital. Personal communication, August 1979.
the abuser. This overinvolvement may even reach the point of incest, especially with female abusers. Further, the abusing offspring may serve a function for the parents, either as a channel for their communication, or as a disrupter whose distracting behavior keeps their own fights from crystallizing. Conversely, the abuser may seek a "sick" state in order to assume a childlike position as the focus of the parents' attention. Consequently, the onset of adolescence, with its threat of losing the adolescent to outsiders, heralds parental panic. The family then becomes stuck at this developmental stage and a chronic, repetitive process sets in, centered on the individuation, growing up, and leaving of the drug abuser.
lt is probably most helpful to view the above process as at least a triadic interaction, involving two adults (usually parents) and the abuser. lf the drug-using youth is male, the mother may lavish her affections on him because she is not getting enough from her husband, while the husband retreats because his wife undercuts him—as, for example, when he tries to discipline the son appropriately. This kind of thinking is much more attuned to the system, and only a few studies and papers have subscribed to it. ln addition, it appears that most family members help to keep the drug abuser in a dependent, incompetent role, the family thus serving to undermine his or her self-esteem. By staying in role and taking drugs, the abuser helps to maintain family stability and homeostasis.
COMPARlSON WlTH OTHER
Since a number of disorders, in addition to drug abuse, show a pattern
lt is legitimate to ask what functions the symptom of drug abuse might serve within an interpersonal or family system. Stemming from earlier discussion of the interdependency and fear of separation that addict families show, drug addiction, especially to heroin, does indeed appear to have many adaptive, functional qualities in addition to its pleasurable features. The major conclusion is that it provides addicts and their families with a paradoxical resolution to their dilemma of maintaining or dissolving the family. The drug's pharmacological effects and the context and implications of its use furnish solutions to this dilemma at several different levels, from individual psychopharmacology to the drug subculture. These functions are described below, and, again, rather than listing the various studies upon which they are based, refer to the original review by Stanton et al. (1978).
The lndividual-Pharmacological Level
Several writers have conceptualized the addict's experience of euphoria as analogous to a symbiotic attachment or fusion with the mothei—a kind of regressed, infantile satiation. lf so, while in this state the addict can feel "close" to mother or family, and also in some ways appear to them much as a child who is clearly not autonomous. On the other hand, heroin blunts the anxiety accompanying separation and individuation, often causes drowsiness, and in effect allows the addict to be separate, distanced, and self-absorbed while physically present. The drug allows both closeness, or infantile behavior, and distance at the same time.
When an addict succeeds or improves, we have noted that family turmoil often ensues. The family seems to be covertly urging the addict to remain incompetent and dependent. Heroin, on the other hand, has been noted to give a sense of new power, omnipotence, and "triumphant success." Perhaps more important is the point made by Ganger and Shugart (1966), however, that under the influence of heroin, addicts become aggressive and assertive toward their families, particularly their parents. ln so doing they become autonomous, individuated, and "free." They appear to stand up for themselves, but do not really. This is actually pseudo-individuation, for addicts' ravings and protestations are typically discounted by the family. The drug is blamed. Without it they "really aren't that way." Through the drug cycle the whole family becomes engaged in a repetitive reenactment of leaving and returning in which the "leaving" phase is neutralized through denial of the possible implications of the addict's assertiveness. ln short, the family is saying, "You don't really hate us—you're just high," and when not influenced by drugs, the addict concurs with, "Yes, l don't really hate you, but when l'm on the drug l can't control myself."
Heroin may offer a compromise in the area of heterosexual relationships. Addicts have been noted not to have teenage crushes, to be more likely than average to engage in homosexual activities, or to be retreating from sexuality. lntense family ties can serve to prevent the addict from developing appropriate relationships with spouses or offspring. lt may be true that the drug produces a kind of sexual
experience, which would partially explain the colorfully eroticized language and loving tenderness that addicts attach to various aspects of their habit; they seem to be addressing it as a love partner. Since it apparently reduces the sex drive also, it can in this way again provide a solution to the addict's dilemma. Through it they can have quasi-sexual experiences without being disloyal to their families, particularly their mothers. They do not have to form heterosexual relationships but instead can relate sexually to the drug.
The Drug Subculture
Other aspects of heroin addiction can help addicts out of their dilemmas, especially those pertaining to extrafamilial systems. Addicts form relationships among members of the drug subculture. They "hustle" and make a lot of money to support their habit. Thus they have friends or peers and are in this way grownup, independent, and "successful." Paradoxically, however, this is not the case, for the more heroin they shoot, the more helpless, dependent, and incompetent they are. ln other words, they can be successful and competent only within the framework of an unsuccessful, incompetent subculture. lt is a limited realm, restricted to people who need help and cannot really be expected to function adequately within society.
Abstinence and the Addict Role
Previously, it was noted how the drug may serve as a problem which keeps the family together. ln this way it transcends its pharmacological effect; it serves more as a symbol of the addict's incompetence and consequent inability to leave the family, or the family's inability to release the addict. Much has been made of the euphoria in drug addiction, but our experience indicates that this is secondary to its function within the family. Given appropriate support, the addict can, for example, tolerate large decreases in methadone levels. By far the greatest resistance is in the final step of going from five mg to zero. lt is an easy step to take, pharmacologically, and its real significance is symbolic. Once this step is taken, the addict is no longer an addict and is making an assertion against the roles played and against the mantle of incompetence. Should the family still need someone in the position of the addicted one, they can bring almost unbearable pressure to beai—so much so that it may cause the addict to slip once again into the addictive cycle.
A HOMEOSTATlC MODEL
The model presented here is of the nonlinear kind and stems from a theoretical tradition extending at least from the earlier works on family homeostasis and triadic systems of Jackson (1957) and Haley (1967, 1973). This model has been presented in more complete form elsewhere (Stanton et al. 1978). ln essence, it is proposed that drug addiction be thought of as part of a cyclical process involving three or more individuals, commonly the addict and two parents. These people form an intimate, interdependent, interpersonal system. At times the equilibrium of this interpersonal system is threatened, such as when discord between the parents is amplified to the point of impending separation. When this happens, addicts become activated, their behavior changes, and they create situations that dramatically focus attention upon themselves. This behavior can take a number of forms. For example, they may lose their temper, come home high, commit a serious crime.