Changes in social attitudes towards drug abuse and in family patterns
Addiction and abuse in the family
Characteristics of families affected by drug dependence
The role of the family physician
Author: P. CROWLEY
Pages: 57 to 62
Creation Date: 1988/01/01
Family therapy has made a substantial contribution to the prevention of drugaddiction. This approach takes fully into account psycho-social relationshipsin families, particularly in families experiencing addiction, as well aschanges in patterns of family life and in social attitudes towards addiction.Drug addiction is a manifestation of serious dysfunctional relationships andinteractions in the family and is often interrelated with child and spouseabuse. Such family situations require multidisciplinary therapy measures forwhich the family, with its network of relationships and behaviouralinteractions, rather than the individual alone, is regarded as the unit oftreatment.
In order to understand addiction, it is necessary not only to focus on its medical symptoms but also to examine theconstellation of behavioural interactions, reflective of psycho-socialdevelopment, in the context of the family, the community and widersocio-economic networks in which the family functions and to which the familyrelates. All these influence, stimulate and regulate individual behaviour.Thus, an important task of a therapist in the process of treating drug-addictedpersons is to gain insight into the subtle, overt and complex dynamics ofsocial interactions and not only into the psychodynamics of individuals.
The theory and concepts of family therapy, which came to be recognized as an independent discipline in the 1950 s, help therapists tounderstand these interaction [ 1] . Whereas classical medicine focuses on the treatment of individuals, family therapy regards the network of relationshipsin which the individual interacts as its unit of treatment. The family isregarded as a psychological unit, the internal processes of which helpestablish and maintain emotional balance [ 2] .
Until the middle of the 1970 s, many of those trying to cope with the syndrome of addiction largely relied on autodidactic methodsthat frequently had strong moral overtones. The International Council onAlcohol and Addictions (ICAA), which was founded in 1907 and is one of theoldest organizations dealing with addiction , set up a special section on thefamily in 1979 to apply the results of research in family therapy to the fieldof addiction. This underlines the short history of the union between familytherapy and addiction.
In the long run, society determines what is regarded as drug abuse and, in this respect, the attitudesand values of society are subject to change. In the late 1960 s, in certainareas of the world, drug taking was identified with protest against authority,with a search for identity or as a mystical experience. The use of alcohol wasviewed as an attempted demonstration of adulthood and as an identification withthe peer group. The drug abuser of that time might be today someone whocasually takes medically prescribed benzodiazephine. In general, there is now atendency towards shifting consumption from illegal to legal drugs; combiningdrugs and alcohol; and increasing drug consumption at home [ 3] .
There are many indications of change and variations in family patterns, especially in countries of North America andWestern Europe. The number of legally defined marriages is decreasing. Thetendency for couples to live together without a legal bond is increasing tosuch an extent that, for certain age groups, unmarried couples are morenumerous than married couples. In Sweden and the United States of America, oneout of every two or three marriages presently result in divorce. In Denmark,France, the Union of Soviet Socialist Republics and in the United Kingdom ofGreat Britain and Northern Ireland, this figure was one in three in 1985. InFrance, about 20 per cent of all children born in 1986 were born out ofwedlock. In Denmark and Sweden, the figure for births out of wedlock ispresently over 40 per cent, appearing to warrant a re-definition of the term"legitimacy" [ 4] .
Research and studies have pointed to the interlinkages between abuse (corporal, emotional, sexual) and addiction infamily situations. Members of families affected by drug dependence are oftenabused or confronted with the abuse of others [ 5-7] . A substantial number of children of such families are victims of various forms of child abuse. Theduration of child abuse tends to last longer with the presence of drugdependency in the family environment.
Crime and victimization data in a number of countries indicate a relatively highincidence of homicide and assault among family members. Females are mostfrequently the victims. In fact, a family member is the most important singlevictim category as far as violence is concerned, and this is a considerablyunder-reported phenomenon [ 8-10] .
In attempting to understand the development and consequences of the types of behaviouralcharacteristics and patterns in some families affected by addiction, it isuseful to examine interrelationships and interactions in the family, which someauthors refer to as sub-systems. These are: (a)between partners; (b)between partners and children; and (c)between children [ 11-13] .
Drug abuse is an indication of dysfunction within family sub-systems. In thisrespect, it is more beneficial to administer treatment within the framework ofthe network of relationships in which the individual interacts (e.g. thefamily) than to treat the individual in isolation.
In this connection, the following questions emerge: Are the changing patterns of familylife resulting in an isolation of the family from other social referencepoints? To what extent can the family be regarded as the patient? Is adysfunctional family a symptom carrier of a "breakdown" taking place within thelarger social system? [ [ 14] , [ 15] ].
A family-therapy approach has made a definitive contribution in the prevention of drug abuse [ ] . Families affected by addiction characterize trends, moderately extant in all families, to a pathological extreme [ [ 17] ].
The repetition of alcohol-related problems over a number of generations in the same family is a well-documentedfact [ 18] . Partners of addicted persons who remarry unconsciously seek similar personality traits in prospective partners.This is found to repeat itself over a number of remarriages.
Children of addicted persons who are not "problematic" (e.g. in terms of schoolachievement) in early childhood can develop difficulties in their relationshipsin marriage. Children who have become surrogate parents in affected familiestend to develop a sensitivity for the feelings and needs of others, yet do notmanage to attain sufficient control or understanding of their own feelings.This hinders the process of successfully building up marital relationships.
Some of the children of drug-dependent and/or abusive parents marry at a very early age. A child is often anxious to move out of thistype of family as quickly as possible, often establishing a relationship withthe first possible partner. A family environment in which there is the presenceof addiction and/or abuse does not lend itself to stable relationships outsidethe family, and such relationships are often marked by failure [ 19] .
Research has found that the so called "social atom" of addicted persons displays considerabledeformation-a devastated core of interpersonal relationships. The central zone,which refers to meaningful relationships with friends and colleagues, haspractically no cohesion; the peripheral zone, which refers to relationshipswith all other persons in everyday life, is relatively crowded [ 20] . This is an indication of the degree of the lack of personal identity, in the case of drug dependence.
The classical relationship between the medical doctor and the patient reinforces passivity by fulfilling the expectation of the patient thatshe or he can be cured by an outside agent. This model of a treatmentrelationship is to be avoided in the field of drug dependence.
A more suitable approach would be to integrate "holistic" medicine and theconcept of family therapy, with due regard to qualified practice in the fieldof treatment of drug dependence. Holistic medicine activates resources withinthe individual in order to cope with personal disturbances, and family therapyviews a patient in the context of mental and physical stabilizing factors in aninteractive environment [ 21] .
The goal of family therapy, in general, is to avoid focusing primary attentionon the affected individual and hence exacerbate the drug problem bystigmatization and drawing attention away from the fact that addiction is asign of dysfunctional relationships. It is highly desirable to take a holisticapproach and, thus, to make a contribution to the prevention and treatment offamilial abuse and drug addiction in the context of a network of relationshipswithin the family and between the family and society.
Experience shows that the treatment of drug-dependent persons in a familysetting is most beneficial when it is provided on a multidisciplinary basis.Such treatment helps the affected person to utilize all her or his potentialresources to overcome the problem.
Multiple family therapy (MFT) is a form of treatment that can be of great assistance in taking familiesout of an isolation that they may experience [ 22] . It enables families to develop social contacts and relationships outside thefamily and to relativize fixations and dependencies, helping to place familyinteraction into perspective [ 23] . The therapy group, which can include up to 10 families, offers an opportunity to rebuildthe core and zones of the social atom or network. Feelings of emotionalrejection, isolation and helplessness, disturbance and other difficulties canmanifest themselves more easily in a MFT setting.
Medical practitioners and specialists are frequently confronted with both abuse and drug addiction in the course oftheir daily practice [ 24] . But sensitivity to the early warning signs of familial abuse and addiction is critical. When a chroniccondition has already set in, there tends to be resistance to change, andtherapy is difficult.
Family physicians are often trusted by families over a number of generations, and many cases of abuse and drugaddiction come to their attention. The medical training of generalpractitioners, however, may not be adequate to enable them to recognize theseproblems at an early stage.
Continuing education of family physicians is beneficial in dealing with such problems. Inthis respect, providing family physicians various opportunities to exchangeexperiences and information and to acquire the essential knowledge and skillswould enable them to deal more expeditiously and efficiently with problemsrelated to drug dependence, at various stages, in the family context.
M. Bowen, "The use of family therapy in clinical practice", Comparative Psychiatry, No.7, 1966.02
H. Stierlin and others, DasErste Familiengespruch (Frankfurt am Main, Klett-Cotta Verlag, 1977).03
United Nations, "Measures to assess drug abuse and the health, social and economic consequences of such abuse: summaryof information from 21 countries", Bulletin on Narcotics (United Nationspublication) vol. 35, No. 3 (1983), pp. 19-32.04
M. Segalen, "Families in the culture of Western European countries", in Proceedings of the International Conference Familiesand Cultures (Paris, United Nations Educational, Scientific and CulturalOrganization, 1987).05
D. Klein, "Violence against women: some considerations regarding its causes and itselimination", Crime and Delinquency . vol. 27, No. 1 (January 1981).06
M. Klagsbrun and D. Davis, "Substance abuse and family interaction", Family Process. vol. 16, 1977, pp. 149-174.07
S. K. Steinmetz, "Violence between family members, a review of the recent literature", Marriage and Family Review, vol.3, 1978, pp. 1-16.08
United Nations, Crime Prevention and Criminal Justice Newsletter, Special issue on violence inthe family, No. 9, December 1983.09
Report of the Secretary-General on the situation of women as victims of crime(A/ CONF.121/16).10
Report of the Secretary-General on the fair treatment of women by the criminal justice system(A/CONF.121/17 and Add. 1).11
A. Adler, Praxis und Theorie der Individualpsychologie (Frankfurt am Main, FischerVerlag, 1974).12
I. Boszormenyi-Nagi and G. M. Spark, Invisible Loyalties (New York, Harper and Row, 1973).13
S. Minuchin, Families and Family Therapy (Cambridge, Harvard University Press, 1976).14
E. Kaufmann and P. Kaufmann, "From a psychodynamic orientation to a structural family therapy approach in the treatment of drugdependency", in Family Therapy of Drug and Alcohol Abuse, E. Kaufmann and P.Kaufmann, eds. (New York, Gardner Press, 1979), pp. 43-54.15
R. J. Noone and R. L. Redding, "Case studies on the family treatment of drug abuse", Family Process. vol. 15, 1976, pp. 325-332.16
M. D. Stanton and T. C. Todd, "Structural family therapy with drug addicts", in Family Therapy of Drug andAlcohol Abuse, E. Kaufmann, ed. (New York, Gardner Press, 1979), pp. 55-69.17
D. Reilly, "Drug-abusing families: interfamilial dynamics and brief triphasic treatment", in Family and Therapy ofDrug and Alcohol Abuse, E. Kaufmann and P. Kaufmann, eds. (New York, GardnerPress, 1979), pp. l15-130.18
R. H. Blum,Horatio Alger's Children (London, Jossey-Bass, 1972).19
J. G. Howells, Principles of Family Psychiatry (New York, Brunner-Mazel, 1975).20
H. Petzold, "An integrated model of identity and its impact on the treatment ofthe drug addict", paper presented at the 12th International Institute on thePrevention and Treatment of Drug Dependence (Lausanne, International Counciland Alcohol and the Addiction, 1982)21
H. H. Reckeweg, Homatoxikologie-Ganzheitsschau einer Synthese der Medizin(Baden-Baden, Aurelia Verlag, 1981).22
H. Laqueur, H. La Burt and E. Morong, "Multiple family therapy: furtherdevelopments", in Changing Families. J. Haley, ed. (New York, Grune andStratton, 1971), pp. 82-9523
E. Kaufmann and P. Kaufmann, "Multiple family therapy with drug abusers", in Family Therapyof Drug and Alcohol Abuse. E. Kaufmann and P. Kaufmann, eds. (New York, GardnerPress, 1979), pp. 81-9324
D. Korczak,"Fragen und Daten zum Drogenkonsum", in Die betäubte Gesel-schaft. D. Korczak, ed. (Frankfurt am Main, Fischer Verlag, 1986), pp. 15-29.