The International Journal of Psychosocial Rehabilitation
 
  Role of Family in Addictive Disorders
K.J. Mathew
Assistant Professor,
Department of Psychiatric Social Work,
Central Institute of Psychiatry,
Ranchi, India.


 Mr. Bibhushan Regmi, MA &  Mr. Lopsang Dinchen Lama, MA
MPhil Psychiatric Social Work Trainees
Department of Psychiatric Social Work,
Central Institute of Psychiatry,
Ranchi, India.




Citation:
Matthew KJ, Regmi B & Lama LD. (2018)   Role of Family in Addictive Disorders
 International Journal of Psychosocial Rehabilitation. Vol 22 (1)  65-75


Abstract
Addictive behaviors are found to be more prevalent among some families in various forms. Although many explanations are provided, there may be various factors and forces associated with family in the initiation, maintenance and recovery of addictive disorders. Modelling, poor parenting skills, structural and relationship issues, support, sociocultural frame work and socio economic status of the family may play different roles in various aspects of addictive disorders.  Comprehensive understandings of such factors are important to deal with the problem of addictive behaviors in various stages and also for prevention.  An appropriate concern and participation of family may lead to better outcomes.

Key words: addictive behaviors, substance use, role of family, prevention of addictive behaviors, treatment of addictive behaviors.


Introduction:
The family is the basic unit in the society and the first agent of socialization. The role of the family makes an individual learn, perceive and value several things consciously and unconsciously. The family’s morals, ethics, rituals as well as the behaviors like how to react to a particular situation and the coping strategies makes an imprint on the individual. Substance use may be considered as appropriate or inappropriate by the family as it is decided by the socio-cultural influences and attitude of the members.  The individual may be learning the substance use as a usual family pattern or as a response to various mismatches in the family environment and the system. In this way working close to the family along with the person addicted to substances is important.

Various theories explain the substance taking and addictive behaviors in different ways. The biological model and disease model says addiction is because the individual is biologically and genetically vulnerable to that. As an illness it may not be reversible. The evolutionary theory says human being has a tendency to acting on pleasurable desires. There may be healthy and unhealthy compelling desires people try to repeat. The self-control is very important to make such desires to track in a positive way. The addictive behaviors in that way as a result of lack of self-control.  Learning theory explain addictive behaviors as learned habits.  The social learning theory focuses on modelling behavior as the key to develop various kinds of addictive behaviors. It explains how family and social interactions and media influence individuals in the process of addiction. Combining with brain reward mechanism operant conditioning explains the maintenance of addictive behaviors in a much better way. Once exposed, the positive effects and feeling of increased wellbeing may reinforce the individual to take the substances again and again. The continuous use of substance may lead to readjustment of dopamine levels and it forces the person to take the substance repeatedly to maintain the happiness of mind. Although the classical conditioning theory has no significant contribution to explain the initiation of substance initiation among individuals it explains how individuals develop various cues associated with addictive behaviors. The cognitive theories explain addiction is because the individuals’ cognitive biases which expect that substance may help them in various to cope with their life problems. According to psychodynamics the ego deficits of individual leads to inadequate control over the impulses of Id and addictive behaviors may be the part of impulses from Id to gratifying pleasure. It also gives importance to the oral fixation which may lead to thump suck and later replace it with various substances (Jacob & Leonard, 1994; Andrews  et al, 1997; West & Hardy, 2005; Ducci & Goldman, 2012).

FAMILY FACTORS ASSOCIATED WITH INITIATION OF ADDICTIVE BEHAVIORS
It was found in many studies that various forms of addictive behaviors and substance use higher among the families with members using substances. The families’ role in this can be evaluated in many perspectives. Firstly the role of genetics as proposed by the biological model of addiction may be important. The same genetic vulnerability of individuals may cause for the increased rate of substance initiation among the members.  It justifies the stand by showing high prevalence of substance use among same family members and by using genetic and family studies. A positive family history of substance use in any first degree relatives is considered to be a high risk factor for developing addictive disorders. Controlled family studies on alcohol addiction show a threefold increase risk of addiction (West & Hardy, 2005; Ducci & Goldman, 2012).

The disease model left limitations to explain the influences of social and peer influences and unable to explain why many people in the same genetic chain not developing dependence and vice versa. The social learning theory may be able to explain the most influential role of family in substance disorders. The children when exposed repeatedly to the situation of substance intake by the elder members may start mimicking them and later develop it as a habit. The highly joyful appearance and the importance given to drugs on special occasions may give them favorable messages about various substances. The children when not provided will start mimicking the behaviors of adult in many ways. The children may observing that the reason elders discussing for the reasons for taking substances like being tensed, anxious, worried, sleeplessness, lack of confidence and also as part of pleasure. For example it is very common that alcoholic men give explanations to their kids that “papa was so tired, and that’s why took a little drink” or “I got a promotion so drink with my friends to share the joy”. When the young people grow-up they may also start behaving in the same way what they observed from the families’ context. Studies showed that adolescent substance intake especially alcohol and smoking is highly influenced by parent’s substance use. Father’s substance use mostly associated positively with boys and mothers with girls (Forney et al, 1989; Andrews, 1993;1997; West & Hardy, 2005).

Parental control both very rigid and highly permissive found to have negative consequences in relation with substance taking behaviors. In an ideal family there will be a system to identify and monitor behavior patterns. The positive and negative reinforcements are important in this context. Failure to identify and control negative behaviors such as addictive behaviors can be considered as the failure of families’ control over members. There are increased chance for the young members to take substances when any of the parent has the habit of taking substance (Wilson, 1980; Baumrind, 1985; Lamborn et al, 1991; Steinberg et al,1994; Walters, 1994; Velleman et al, 2005; West & Hardy, 2005).

In relation with family functioning and initiating addictive behaviors two kinds of issues are associated. They are issues of relationship and family structure. The relationship talks about the quality of intimate relationships between family members such as cohesion, warmth, communication etc. The structure talks about the aspects about how the family consisted such as joint or nuclear, single parent, family size etc. Studies concluded that relationship aspects have significantly higher influence in drug related behaviors (Coomds & Paulson, 1988; Piercy et al, 1991; Velleman et al, 2005).

Lack of connectedness and support from family may lead to addictive behaviors as a strategy to manage negative emotions and also for developing social networks. Social support found to have a consistent predictor for substance use among all age groups. The support and guidance provided at the time of stress and difficult situations found to be protective factor against initiating various drugs. Perceived social support is found to be correlated with better coping skills of individuals and protecting against the addictive behaviors. Lack of perceived social support and pro-social networks found to associate with addictive behaviors in all age groups (Dobkin et al, 2002; Lonczak, 2007; Garmendia et al, 2008).

The higher number of offspring with substance behaviors can also because of sociocultural influences. In many cultures the cultivation and use various forms of substances are socially sanctioned. Cannabis, opium and various forms of alcohol has been widely used worldwide as part of cultural and religious procedures. The drugs especially alcohol and nicotine are widely used and sanctioned during celebrations and partying. Substances especially alcohol consumption considered to be a way to express solidarity, and sociability. The alcohol also considered as a symbol of joy, symbol of social status, and affiliation. Alcohol and cannabis widely used for blessing religious ceremonies in many cultures (Bobo & Husten, 2000; Eckersley, 2005; UNODC, 2007; ICMR Bulletin, 2008; Tandon, 2015).  The consumption of some forms of alcohol was promoted by the Kings in India among the warriors as they believed it will help in developing courage. The alcoholic beverages like toddy, arrack and mahua used in different part in India and many people believes that  limited intake of such drinks is healthy and promote good health. Hence it served in many family and social functions with or without restrictions to children and females. Variety of preparations of opium was popular among various Asian communities. They believed that it is associated with good health, longevity, and increased sexual pleasure. The opium preparations also used for treating stress related issues. Cannabis considered being very divine in India and used for religious purposes. Besides that in India cannabis preparations are widely used in Ayurveda medication to treat a variety of issues. It used as a hypnotic, analgesic and antispasmodic agent and to treat dyspepsia, pain, rheumatism, dysentery, diarrhoea, hysteria etc. In northwestern India a kind of drink called ‘Thandai’ which is prepared from various herbs, fruits and cannabis found to be helpful in surviving heat in summers. Many often such situations facilitate opportunities to individuals to experiment substances at first time (Chopra & Chopra 1957; Shukla, 1979; Abel, 1980; Chopra & Chopra, 1990; Ganguly et al 1995; Dorabjee & Samson, 2000; ICMR bulletin, 2008). 

Studies have found that socio-economic status also play major role in substance use in various ways. The culture of social drinking and partying give more tolerant attitude toward various drugs especially alcohol. The working class parents are not getting sufficient time to spend with their children.  The isolation creates much psychological distress and may lead to addictive behaviors. Lack of parental control may moderate the issue. Along with the cultural factors, low income families may related to substance use as a coping mechanism because of increased stress and less access to alternative activities, unemployment, poor parenting and socialization (Hanson and Chen, 2007; Luthar and Goldstein, 2008; Huckle et al., 2010).

FAMILY FACTORS ASSOCIATED WITH MAINTENANCE
The addictive behaviors in many cases maintained because of factors related to family. Starting with genetic and biological theories addictive behaviors are because the individuals are genetically programmed in that way and once started it is irreversible. Families’ genetic loading may be playing major role in the initiation and maintenance of addictive behavior. According to the neuroscientific theories the brain reward mechanisms plays major role maintaining the addictive behaviors. But these theories are unable to explain why all people in a family not developing the addictive behaviors and differences among individuals and how people are remaining abstinent and the efforts of current treatment advances (West & Hardy, 2005; Perring, 2011; Reilly et al, 2017.).
Modelling theory explains more about the initiation of drugs but also have influences in maintaining.  The individuals may learn many situations in association with addictive behaviors, such as social gatherings, festivals, family gatherings etc. As many people considers it is not appropriate to deny a drink or smoke in certain situations they continue with their habits. People and families who tend to have more such situations are vulnerable to continue their addictive behaviors (Andrews et al, 1997; West & Hardy, 2005).

The classical conditioning theory mostly explains how people develop different cues associated with the substance taking behaviors. It may play significant role in the maintaining of drug use especially alcohol, nicotine, cannabis etc.  In the process of life the individuals may identify substance use as a factor which gives relief from negative emotions and enhance the positive feelings. They may identify many situations as cues associated with their habits. Certain situations as stressful and the use of substances may be reducing the negative emotions. However in some other situations the substances may be justified for enhancing positive emotions, such as in family gatherings. Cues are highly associated with maintaining addictive behaviors as it is associated with craving (West & Hardy, 2005; Lamb et al, 2016).

There may be many dysfunctional relationship patterns among family members which may directly or indirectly enables the addictive behaviors (Cermak, 1986). The quality of relationships between family members especially the bond between the parent children subsystems found to have significant influence on drug use among family members.  The strong bonds found to be discouraging addictive behaviors. When the children like their parents and consider them as role models, it may lead to high levels of pro-healthy behaviors and same time with decreased tendency to develop deviant behaviors (Kandel & Andrews, 1987; Bahr et al, 1995; Duncan et al, 1995; Velleman et al, 2005). Communication in family is a broad area and has various effects on its members. The quantity and quality of communication between members in terms of both verbal and nonverbal forms, clarity of communication, poorly communicated expectations, inconsistency and contradicting messages and conflicts were found to be associated with member’s addictive behaviors (Brook et al, 1990; Kosterman et al, 1995; Velleman et al, 2005). Expression of warmth, support, clarity on prosocial expectations, consistency in messages and moderate level control found to be associated with healthy outcomes   (Coie et al, 1993; Yoshikawa, 1994]. Good parent managing skills may decrease the chance of children’s contact with deviant groups. Both excessive control and permissiveness may lead to deviant behaviors.  Severe forms of punishments and criticisms were predicted negative outcomes. Parents using positive reinforcements, consistent control, responsible, moderately demanding and appreciating self-efficiency of children may protect them from addictive behaviors (Wilson, 1980; Baumrind, 1985; Lamborn et al, 1991; Steinberg et al, 1994; Walters, 1994; Baumrind, 1989; Velleman et al, 2005).

As discussed earlier the socio-cultural frame work of the families also important in maintaining various substance use and dependence. There may be various beliefs and attitudes toward various substances.  Peoples beliefs about the effects of various substances found to be differing from place to place and among various ethnic groups. It is observed that people in certain ethnic groups expects benefits out of substances related to personal and social domain. Many culture substances are widely used for medicinal purpose also. In such contexts family usually take a more favorable stand toward such substances and it may contribute to maintaining the use of substances (Christiansen & Teahan, 1987; Johnstone 1994; ICMR Bulletin, 2008).

FAMILY FACTORS ASSOCIATED WITH RELAPSE AND RECOVERY
Any problem in the family dynamics found to be increase the chance of relapse. Problems like family boundary issues, communication problems, lack of cohesion, role dysfunctions, and behavior problems may contribute to relapse and an appropriate management of such issues may lead to recovery.  Due to lack of open interaction and communication between patients and family members increases the risk of relapse (Turner et al, 1993; Flora & Stalikas, 2013).
A strong social support combined with self-efficacy found to be strong indicator for recovery from addictive disorders. Social support is a combination of diverse supporting forces. Simply staying together may not always provide the support needed. Poor parent-adolescent communication, poor family management skills, lack of parental warmth,  affective response, lack of parental involvement, absence of parents due to divorce, or death all are found to be associated with  risk of relapse (Dodgen & Shea, 2000; Fraser, 2002).

There are good evidences to show the family interventions are efficient in cases of addictive behaviors.  These therapies address the dysfunctional family domains with respect to unhealthy thoughts, attitudes and behaviors. Productive change comes through improving communication skills, exploring relationship barriers, enhancement of trust and dealing with other co morbidities. These factors enhance the compliance which can result in good response and play a very vital role in recovery of addictive disorders. Giving proper psycho education also found effective as it enables family members to know the addictive disorders in a very holistic way with respect to physical, psychological and social domains. This line of therapy can also focus on support from the family members, healthy coping styles, teaching difference between enabling behavior and supportive behavior for recovery, the importance of effective communication and boundaries. Activities that generate a sense of collective responsibility and we feeling such as solving family problems, taking over responsibility if the situation requires, or doing activities together example cleaning the house, having dinner, going for picnics etc. are usually encouraged (Nattala et al 2010; Arria et al, 2013).

It is very common that the family members ask the individual on treatment to stop their habits but continue with their own habits. The family often fails to understand the importance of collective responsibility and keeping away the patient from temptation. The addictive behaviors like other can be learned and unlearned. The unlearned behavior may learn again and can be relapsed by the influence of continuous substance use of other family members (Marlatt & Gordon, 1985). Relapse of adolescent substance abuse found to be associated with rejection by parents, parental and sibling substance use, divorce in family, and conflict in family. It is also seen that substance abusers are more liable to report a poor relationship with their parents compared to non-users (Cattarello et al, 1995; Fraser, 2002; Van Der Westhuizen, 2007).

FAMILY’S ROLE IN PREVENTING ADDICTIVE DISORDERS
There are a variety of effective family-based preventive intervention approaches for substance abuse. Some programs mainly focus on providing skills to parents to keep their children away from addictive behaviors. The training includes parenting skills, developing healthy bonds, communication skills and promoting prosocial skills. Another type of family-based prevention focuses on teaching family skills with parents and children together. The focuses of such programs are mainly improving the quality of family functioning, communication and control. The changes in the unhealthy dynamics or pathological family process may lead to substance taking and modifying or removal of such factors may lead to prevention of addictive behaviors. Family therapy interventions are beneficial for those families who are experiencing problematic relationships.  The home based interventions  focused on identifying family characteristics, manners and attitude that may influence the addictive behaviors of the members found to be effective. The interventions include the parental supervision and support, rule setting, communication, availability and acceptability to substances, socio cultural factors etc.  (Lochman & van den Steenhoven, 2002; Botvin & Griffin, 2010).
 

FAMILY FACTORS AND ADDICTIVE BEHAVIORS IN CHILD AND ADOLESCENT POPULATION
Young individuals with very positive relationships with their parents tend to be less influenced by the peer groups and are less engaged in substance taking activities. Parents who are very permissive and authoritarian may exaggerate the risk of children to develop addictive disorders (Velleman et al, 2005). Parental substance use found to be the significant predictor for initiating substance use among adolescent population. At the same time the children of parent with substance use found to be using more varieties substance than their parents. Studies observed that parental substance use also correlated with the maintenance of the alcohol use among the adolescents. Any kind of favoring attitude toward substances found to be associated with maintenance of substance use in various forms. Parents cautionary statements found to have positive effects on initiating addictive behaviors but inconclusive about the maintenance of the substance use (Kandel,1974Brook et al, 1986; Andrew et al,1993; 1997).

Social support and social connectedness also play significant role in all kind of addictive behaviors in all stages. Social support and network found to be protective and helpful to individuals to cope better with stressful situations. Despite this social support is also found to be associated with developing healthy coping style among individuals. The perception of high social support has been correlated with less substance use. Social support is a strong predictor for treatment response and recovery from addictive disorders (Frazier et al, 2000; Dobkin et al, 2002; Lin et al, 2011).

Social support and social connectedness also found to be associated with other forms of addiction like internet and social media. The increased use of social media may be an attempt to harvest social support and social networks. Though it was seen that internet use can enhance social connectedness compulsive internet use has been associated with poor direct social connectedness and dysfunctional outcomes. Families having divorced parent, are less organized and has less warmth have more addiction towards the internet.  A decreased level of communication between the family members observed among the extreme internet users (Kraut et al, 2002; Lorento, 2002; Li and Zang, 2004; Ghasemi & Ahmadi, 2010; Li et al, 2014; Şenormancıet al, 2014; Habibi et al, 2015; McIntyre et al., 2015).

GERIATRIC POPULATION
The loss of the partner and lack of social support are the factors highlighted by studies in associated with the substance dependence on elder people. The loss of the partner may make the elder ones feel isolated and they may initiate the substance use as an attempt to cope with difficulties. Elderlies who have less support from their family have been found to have more drinking problems. Social support independently predicts the late onset addictive behavior especially after the retirement. Studies show that after the retirement people loss their social networks and feels isolated and idle. Combined with this there may be problems in relationships with the family member and spouses because of various reasons. When family members are unable to support them adequately they may going to addictive behaviors alone or with peers to overcome the isolation.  There has been prediction of high alcohol use after a stressor like a marital discord and dissatisfaction with the relationship. Elderly who had more support from their wife had less drinking pattern and problems. The married people found to have less addictive disorders. The problem drinkers in elderly had less children, spouse, extended relatives and resources (Pearlin & Schooler, 1978; Barr, 1985; Meyers, 1985; Schonfeld & Dupree, 1991; Meyers et al, 2002; Morgan & Brosi, 2007; Stelle & Scott, 2007).

FEMALE POPULATION
Among various culture and populations different factors are associated with substance use among women. Family history of substance use especially alcohol found to be a significant predictor. In such conditions the females may initiate addictive behaviors early in the life usually at their adolescent period. The late onset additive behaviors are frequently associated with relationship issues with spouse and family.  Marital discord with husband and issues related with fidelity and extra marital affairs are very common. Many studies observed that woman start taking substances as an attempt to cope with lack of social support. In many cases it was seen that women suffering from alcohol related problem was divorced by their spouses and was also deserted by the family members. All kind of abuses are found to be strongly associated with substance use among female population. Because of many stigmas and social taboos woman not discloses their history of abuses to any one and try to overcome their emotional difficulties through addictive behaviors (Boyd & Mackey, 2000; Lee & Kim, 2000; Lim, 2002; Choi, 2003; 2005; Kim, 2006; Kim & Kim, 2008). The help seeking also found to be different among men and woman. Families’ found to have more stigma and negative attitude toward females than males. This may result in lot of conflicts and fights between family members. Often such hostile attitude may leads to hiding the substance using behaviors from the family. Studies found that woman often hospitalize against their will and treated badly by the family members. The conflict can even lead to severe consequences like divorce and separation. (Lee & Kim, 2000; Jeong, 2003; Kim, & Kim, 2008).

CONCLUSION
Addictive behaviors are very complex and need a multidimensional approaches to deal with it. Family plays a very significant role in developing, maintaining and recovering from addictive behaviors. The factor may different at different stages and populations. It also requires a broad understanding of socio-cultural influences. Family should provide freedom, space and stability to enable members to grow and develop in various domains. At the same time family as a dynamic system has to achieve goals and objectives to perform regular day to day tasks. In that way family may share the responsibility for any deviant behavior and suffer from it. A comprehensive understanding about the role of family in addictive disorders may help the clinicians and families to deal with the problem in a better way.         

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