In developing a theory of drug abuse, my colleagues1 and I 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 throuqh a collaborative. effort with a number of colleagues, including Thomas C. Todd, Ph.D.: David B. Heard, Ph.D.: Sam Kirschner, Ph.D.; Jerry I. 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). In 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).

It 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.

NONLINEAR CAUSALITY

In 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.

FAMILY LIFE CYCLE

It 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.

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.

TRAUMATIC LOSS

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.

In 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).

It 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.

In 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 SEPARATION

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.

It 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.”

ADDICT-FAMILY CONTEXT

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 Italy 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.

In sum, the accumulating evidence has tended to yield data consistent with a close addict-family tie hypothesis.

FAMILY STRUCTURE

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 the abuser. [Mintz, University of California, Los Angeles, and Brentwood VA Hospital. Personal communication, August 1979.]

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.

It is probably most helpful to view the above process as at least a triadic interaction, involving two adults (usually parents) and the abuser. If 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. In 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.

COMPARISON WITH OTHER SYMPTOMS OR DISORDERS

Since a number of disorders, in addition to drug abuse, show a pattern of overinvolvement by one parent and distance/absence by the other, the question arises as to how drug abusers’ families differ from other dysfunctional families.

Stanton et al. (1978) have tried to clarify this issue, drawing both from the literature and from their own studies.

In brief, the cluster of distinguishing factors for addict families appears to include the following:

(a) There is a higher frequency of multigenerational chemical dependency--particularly alcohol among males--plus a propensity for other addiction-like behaviors such as gambling and watching television. (Such practices provide modeling for children and also can develop into family “traditions.”)

(b) There appears to be more primitive and direct expression of conflict, with quite explicit (versus covert) alliances, for example, between addict and overinvolved parent.

(c) Addict parents’ behavior is characterized as “conspicuously unschizophrenic” in quality.

(d) Addicts may have a peer group or subculture to which they (briefly) retreat following family conflict--the illusion of independence is greater.

(e) Mothers of addicts display “symbiotic” childrearing practices further into the life of the child and show greater symbiotic needs, than mothers of schizophrenics and normals.

(f) Again, there is a preponderance of death themes and premature, unexpected, or untimely deaths within the family.

(g) The symptom of addiction provides a form of “pseudo-individuation” at several levels, extending from the individual-pharmacological level to that of the drug subculture. (See discussion that follows.)

(h) The aforementioned rate of addiction among offspring of immigrants is greater than might be expected, suggesting the importance of acculturation and parent-child cultural disparity in addiction.

SYMPTOM FUNCTION

It 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 Individual-Pharmacological Level Several writers have conceptualized the addict’s experience of euphoria as analogous to a symbiotic attachment or fusion with the mother--a kind of regressed, infantile satiation. If 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. Aggressive Behavior 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. In 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.

In 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, I don’t really hate you, but when I’m on the drug I can’t control myself.”

Heterosexual Relationships 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. Intense family ties can serve to prevent the addict from developing appropriate relationships with spouses or offspring.

It 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. In other words, they can be successful and competent only within the framework of an unsuccessful, incompetent subculture.

It is a limited realm, restricted to people who need help and cannot really be expected to function adequately within society.

bstinence and the Addict Role Previously, it was noted how the drug may serve as a problem which keeps the family together. In 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. It 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 bear--so much so that it may cause the addict to slip once again into the addictive cycle.

A HOMEOSTATIC 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).

In 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 chances, 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, 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

------
3 In 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.
------

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 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.

-------

From N.I.D.A. Monograph 30 - Theories on Drug Abuse: Selected Contemporary Perspectives.  [Page for pdf download, which includes diagrams and reference list.]