Role of Family in Addictive Disorders K.J. MathewAssistant Professor,
Department of Psychiatric Social Work,
Central Institute of Psychiatry,
Ranchi, India. Mr. Bibhushan Regmi, MA & Mr. Lopsang Dinchen Lama
MPhil Psychiatric Social Work Trainees
Department of Psychiatric Social Work,
Central Institute of Psychiatry,
Matthew KJ, Regmi B & Lama LD. (2018) Role of Family in Addictive Disorders International Journal of Psychosocial Rehabilitation. Vol 22 (1) 65-75
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.
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.
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).
ASSOCIATED WITH INITIATION OF ADDICTIVE BEHAVIORS
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).
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 &
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;
et al, 2005; West & Hardy, 2005).
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).
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,
et al, 2008).
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).
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
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,
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).
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).
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
FAMILY’S ROLE IN PREVENTING ADDICTIVE
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
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
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).
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
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
2002; Li and Zang, 2004; Ghasemi & Ahmadi, 2010; Li et al, 2014;
Şenormancıet al, 2014; Habibi et al, 2015; McIntyre et al., 2015).
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).
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).
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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