or overdose on drugs. Whatever its form, however, this action allows the parents to shift focus from their marital conflict to a parental overinvolvement with the child. In effect, the movement is from an unstable dyadic interaction (e.g., parents alone) to a more stable triadic interaction (parents and addict). By focusing on the problems of the addict, no matter how severe or life threatening, the parents choose a course that is apparently safer than dealing with long-standing marital conflicts. Consequently--after the marital crisis has been successfully avoided--the addict shifts to a less provocative stance and begins to behave more competently. This is a new step in the sequence. As the addict demonstrates increased competence, indicating the ability to function independently of the family--for example, by getting a job, getting married, enrolling in a drug treatment program, or detoxifying-the parents are left to deal with their still unresolved conflicts. At this point in the cycle, marital tensions increase and the threat of separation arises. The addict then behaves in an attention-getting or self-destructive way, and the dysfunctional triadic cycle is again completed.

This cycle can vary in its intensity. It may occur in subdued form in treatment sessions or during day-to-day interactions and conversations around the home. For example, a parent hinting at vacationing without the spouse may trigger a spurt of loud talking by the addict. If the stakes are increased, the cycle becomes more explosive and the actions of all participants grow more serious and more dramatic, e.g., the parents threatening divorce might well be followed by the addict's overdosing. Whatever the intensity level, however, we have observed such patterns so often that we have almost come to take them for granted. Viewed from this perspective, the behavior of the addict serves an important protective function and helps to maintain the homeostatic balance of the family system.

The onset of the addiction cycle appears in many cases to occur at the time of adolescence and is intensified as issues of the addict's leaving home come to the fore. This developmental stage heralds difficult times for most families and requires that the parents renegotiate their relationship--a relationship which will not include this child. However, since the parents of the addict are unable to relate to each other satisfactorily, the family reacts with intense fear when the integrity of the triadic relationship is threatened. Thus we find that most addicts' families become stabilized or stuck at this developmental stage in such a way that the addict remains intimately involved with them on a chronic basis. In addition to staying closely tied to the home, the failure to separate and become autonomous may take several other forms, and the child may (a) fail to develop stable, intimate (particularly heterosexual) relationships outside the family; (b) fail to become involved in a stable job, school, or other age-appropriate activity; (c) obtain work which is well below his or her capabilities; (d) become involved in criminal activities; (e) become an addict.

THE ABUSER'S FAMILY OF PROCREATION

Concerning marriage and the family of procreation, it has generally been concluded that the (usually heterosexual) dyadic relationships that abusers, especially addicts, become involved in are a repetition of the nuclear family of origin, with roles and interaction patterns similar to those seen with the opposite-sex parent. (See Stanton 1979b and 1980 for a review of studies supporting this and subsequent conclusions.)

In a certain number of these marriages both spouses are addicted, although it is more common for one or neither or them to be drug dependent at the beginning of the relationship. If the marital union is formed during addiction, it is more likely to dissolve after methadone treatment than if initiated at some other time. Also, nonaddicted wives tend to find their husbands' methadone program to be more satisfactory than do addicted wives. Equally important, the rate of marriage for male addicts is half that which would be expected, while the rate for multiple marriages is above average for both sexes. A number of authors have noted how parental permission is often quite tentative for addicts to have viable marital relationships. They often flee into marriage only to return home, defeated, as a result of parental influence or "pull."

In our own studies of male addicts (Stanton et al. 1978) we have noted that if the addict had not "checked in" at home recently or if the parents had some other reason to fear they were "losing" him, a crisis often occurred in their home--often a fight between them--and the son was alerted to it. At that point he was apt to start a fight with his wife--a move which served two purposes. It showed the parents that they had not lost him to marriage, and it gave him an excuse to return home to help, since he had "no place else to go." Usually he succeeded in diverting attention from the problem in the parental home and once again functioned to reduce conflicts between adults.

At other times the precipitating event(s) were less obvious and he and his wife fell into a cycle of periodic altercations. Their temporal regularity seemed almost servo-controlled. 3 These appear to be maintenance cycles. They may not have resulted in his moving out, but instead he would show up with some regularity at his parents' home to complain about connubial problems. He seemed to be saying, "I just dropped by to let you know that things aren't going well and you haven't lost me." (In one case, every time the addict's mother called him, he would tell her he had just had a fight with his wife, even if he had not--an ingenious way of keeping both systems simultaneously intact and pacified.) Marital battles thus became a functional part of the intergenerational homeostatic system, possessing both adaptive and sacrificial qualities.

SINGLE-PARENT FAMILIES

In many drug abuser families-of-origin, one parent (usually father) is absent. In such cases, one would think that a triadic model (as above) would not apply, and that a dyadic framework, e.g., one encompassing mother and son, would be more fitting. It would also appear to be more parsimonious and less complicated. Nonetheless, we have found (Stanton et al. 1978) that when the matter is pursued closely, a third important member generally pops up as an active participant in the interaction. Usually the triadic system is of a less obvious form, such as a covert disagreement between mother and grandmother, or mother and ex-husband. This is consonant with a point made emphatically by Haley (1976) that at least two adults are

3In this case, "servo-controlled" refers to an automatic return to a prior behavioral state, once a certain limit (i.e., the end of a time period) is reached.

usually involved in an offspring's problem and that clinicians should look for a triangle consisting of an overinvolved parent-child dyad and a more peripheral parent, grandparent, or parent surrogate. Thus it has been our experience that in addition to the (male) addict and his mother, the triad may include mother's boyfriend, an estranged parent, a grandparent, or some other relative. These alternative systems appear to exhibit patterns and cycles similar to those in which both parents are present and, again, revolve around interruption by the abuser of conflicts between adult members. However, achieving separation and independence is even more of an issue in single-parent families, since mother may be left alone with few psychological resources if the drug abuser departs.

Self-Esteem Theory of
Drug Abuse

R. A. Steffenhagen, Ph.D.

To be of value a theory must predict as well as explain the phenomena after the fact. The self-esteem theory postulates that all behavior is mediated by the individual's attempt to protect the "self" within the social milieu.

This theory is a developmental one emanating from an Adlerian approach in which self-esteem is seen as the main psychodynamic mechanism underlying all drug use and abuse. The self-esteem concept develops out of Adler's Individual Psychology, more precisely the Psychology of Self-Esteem, in which the underlying motive of human behavior is the preservation of the concept of the "self" (Ansbacher and Ansbacher 1956). The preservation of the concept of "self" is the most important variable in understanding the initiation, continuation, and cessation of drug use, and further explains why the rehabilitation process frequently results in relapse.

The theory will not only account for the initiation into drug use (the social milieu) but will determine the course the pattern will take (vis-avis self-esteem) in terms of continuation, cessation, and/or relapse. The etiology of drug use does not lie in the personality of the individual (addiction proneness) or in family constellations (drug use as a behavioral model), but in availability, social acceptability, and social pressure. It must be noted that the type of dependency is conditioned by the culture. Dependency on amphetamines, for example, could not have existed before their discovery in the early 1900s, medical use in the 1930s, and post-World War II street use. Alcohol (as a social drug) was the main drug of abuse until the post-World War II period in the United States, and marijuana was the drug of abuse in India. Today, these two countries are in a state of social change, and the youths of both countries are becoming users and abusers of socially unacceptable drugs--marijuana in the United States and alcohol in India (Cohen 1969). Thus, the culture determines the types of drugs available, while social pressure and social acceptability further determine the type and pattern of use. Social pressure may lead one both into and out of drug abuse. This has become evident in some of the street gangs in New York City, where youths would become addicted to heroin because of peer pressure and then would later cease as a result

of the same pressure. A similar situation was true in Vietnam, where many of the soldiers who became addicted to heroin were subsequently cured of their addiction. The reasons for relapse will be discussed later.

The theory incorporates several of Adler's key concepts. Self-esteem does not emerge full blown at birth but is developed slowly during the socialization process. The foundation is developed early in life and is present at the time the prototype of the personality is formed. This does not mean, however, that self-esteem cannot be changed positively or negatively later, since the individual is very much responsive to social pressure. The concepts which will be elucidated in this paper are (1) inferiority-superiority, (2) social interest, (3) goal orientation, and (4) lifestyle. In the context of this discussion, the development of self-esteem and the social milieu will be looked at to explain how social pressures affect the individual.

INFERIORITY AND SUPERIORITY

Paramount to Adler's Individual Psychology are the concept(s) of inferiority and superiority. All children begin life in an inferior position, and much of their early socialization consists of learning to cope with feelings of inferiority. Exposed to an adult milieu, they perceive themselves as small and weak, inadequate and inferior. Learning to cope with these inferiority feelings, which dominate the behavior of all individuals to a lesser or greater degree, becomes the basis for goal orientation. The uniqueness of human beings stems from their means of dealing with these feelings, their style of life. Coping mechanisms are developed in accord with individual choices (as Tillich says, "Man is his choices.") or goals, which can only be understood in relationship to lifestyle and social milieu. The feelings of inferiority reflect the extent to which the individual perceives himself/ herself as able or unable to obtain goals. The ability to attain goals is the result of psychological, biological, and sociological factors, while the technique chosen to deal with inferiority is the result of a person's lifestyle.

On the other hand, expressions of superiority can become a compensatory mechanism in which the individual's overt behavior becomes a mask for inner feelings of inferiority.

SOCIAL INTEREST

Foremost in the development of a healthy personality is the development of social interest, because it is only through social participation that the individual can deal with feelings of inferiority and develop high self-esteem. Within the Adlerian paradigm, lack of social interest is always present in a neurotic person. Humans are social animals, and most conscious behavior is spent in contact with other individuals in the normal pursuit of work, play, and raising a family. The fundamental conditioning technique during the socialization process centers around praise and blame. Praise is good for the ego and helps in the development of self-esteem when it is given for socially useful actions. When the mother's rewards are given for actions which are socially useless or in such a pampering fashion that the individual only gets