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Fam Proc 16:149-164, 1977

Substance Abuse and Family Interaction MICHELINE KLAGSBRUN, D.C.P.a DONALD I. DAVIS, M.D.a aCenter for Family Research, Department of Psychiatry and Behavioral Sciences, George Washington University School of Medicine, Washington, D.C.

The authors propose that substance use and abuse may be understood and effectively treated when the individual user or abuser is viewed in the context of his family or stable living group. This viewpoint attributes an important role in the maintenance of individual substance abuse to interactional processes within the family system. The theoretical assumptions implied by this viewpoint are discussed. A selective literature review examines the available evidence, from both experimental and clinical-descriptive studies, that is relevant to this proposal. The next step toward a more systematic investigation of these ideas is outlined, including testable hypotheses, methodological issues and problems, and potentially useful techniques.

INTRODUCTION This paper will attempt to organize and integrate current information about the family and substance abuse, with a view to understanding the "symptom" of individual abuse in the context of the family system. To this end, we present a critical review of the literature that we hope will suggest areas for further empirical investigation. This review is not intended as a general survey of all the literature in this area but as a selective review with a focus on functional relations between the individual and the family system; we hope it will prove at least as rewarding as the more traditional "composite-of-traits" approach to these families. We shall also discuss the particular line of investigation that we see as a natural outcome of our current work, outlining the rationale and methodology involved. Investigators in both the family and the substance-abuse fields have proposed (or, more often, implied) a variety of definitions as to what constitutes a "family" or an "abuser" of drugs or alcohol. For our purposes, we have defined family as a relatively stable living group, a distinct psychosocial unit, that comprises at least some form of the "nuclear" family and may include other members not necessarily blood-or marriage-related. By substance abuser, we refer to an individual who uses on his own initiative any psychoactive1 drug in such a way that his well-being or social functioning is impaired. Substances such as tea, coffee, and cigarettes can be classified as drugs, and the first two are at least minimally psychoactive. Although what we shall discuss here is relevant to their abuse, studies of these substances are beyond the scope of this review. This distinction may seem arbitrary, since not only tobacco and caffeine but also food may be considered as substances that promote a psychological dependency that shares many of the functional characteristics of other drug dependency. Nonetheless, too broad a definition of "substance" would render this investigation diffuse and unmanageable, and a more restricted focus is necessary for our purposes. We are fully aware of the moralistic implications carried by the term "abuse." We could have chosen the less value-laden term "drug dependency" as defined by Greaves (44): "The use of any psychoactive drug, including alcohol, to the extent that the use of the drug or drugs becomes such an integral part of the life style of the individual that its nonavailability or non-use results in subjective distress." This definition implies that dependency on drugs is a similar quality to reliance (practical and emotional) on anything that is part of one's preferred way of life  for example, a functioning automobile, an appointment book, the presence of a loved one  all of which may provoke subjective distress if not available. The term "abuse" conveys more adequately the compromise of personal freedom that dependence on psychoactive drugs involves and reflects our belief that the individual's choice of drugs as a mode of coping with life is actually the choice of a constricting pseudosolution that precludes him from exploring other, more functional ways to resolve his difficulties. The social acceptability of drugs as a solution to conflict and the right to self-medication in times of stress, anxiety, or depression are relatively new phenomena that may influence drug-taking patterns to such an extent that comparison between generations must be made with caution. Given this new availability and cultural endorsement of drugs, can we determine the part that a drug-abuser's family plays in the choice of this particular coping mechanism?

Statement of the Problem In the treatment of drug abusers and alcoholics, there has been a recent shift of interest in some quarters away from the model of the identified patient, in which deviant behavior is viewed as an expression of sickness within the individual, to a model in which it is seen as adaptive in its context (24).

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A small but steadily increasing flow of literature supports the notion that the family system has a significant role in maintaining a substance-abuse problem (93). Simultaneously, there is a developing lore among experienced clinicians in substance-abuse treatment that the family or kinship network must be involved for optimal treatment (50). Personal interviews by one of the authors with more than a dozen clinicians and clinician-administrators at leading substance-abuse treatment programs support this conclusion. A typical comment from professionals who have, until recently, oriented their inpatient and outpatient programs along the lines of medical management and nonfamily therapy groups is that made by Leon Marder, Medical Director of Rancho Los Amigos Hospital, Los Angeles, California, that their once-a-week family group sessions are "the single most useful thing we do" (69). David Wellisch (105) captured the spirit of those few professionals in the substance-abuse field who already have a family orientation by saying that the drug-abuser families "[are among] the hardest families to treat, but the family approach is the only approach that will work" (personal communication). However, the development of therapeutic techniques in this area has been in advance of theory-building, leaving a conceptual gap. There is a body of clinical intuition and hypothesis-generating family studies that calls for further study of the role of the family in substance abuse. The next question is, what should be studied and how? Can the maintenance of substance abuse in the individual be understood as a vital expression of the malaise of the family group? Is the well-being of a subsystem being sacrificed in order to maintain functioning and integration of the system? Before attempting to formulate such hypotheses, let us turn to the empirical evidence in the literature.

SURVEY OF THE LITERATURE Previous research into the family and substance abuse (excluding purely clinical reports) can be broadly divided into (a) clinical-descriptive studies on a limited number of cases; (b) controlled, correlative studies of the association between substance use in parents and children; and (c) largely uncontrolled studies (with a few exceptions) that use a variety of measures in the attempt to delineate the characteristics of substance abusers' families. (See The clinical-descriptive studies will be discussed fully, as they seem to bear the most relevance to our approach. However, we shall first briefly review the findings of the last two types of studies, which are also of substantial importance. There is considerable evidence that adolescent drug use is related to parental use of substances, particularly alcohol (94, 91, 2). This association has been demonstrated for male and female drug abusers alike, in various countries, for the whole spectrum of drugs from marijuana to narcotics, and in groups as diverse as juvenile offenders and female college students (94). Even where peer influences are clearly delineated and powerful, the importance of parental "modeling" persists (94). Type (c) studies are strongly reminiscent of earlier attempts to depict the typical personality of the alcoholic or drug abuser. There are basically two approaches  investigating the children of deviant parents (76, 18) and the parents of deviant children (13, 25). The substance abuser's mother is most frequently the focus of attention (57, 61, 36) and is described as using her son in the gratification of her unconscious needs, overprotecting and controlling him in such a way as to maintain his infantile dependence on her. Often it is found that one or the other of the parents (usually the father) is absent from the the home environment (41, 19, 17, 15, 70). In their study of 74 amphetamine abusers, Hawks et al. (48) report typical findings: 34 of the patients "suffered parental bereavement or separation before age 16," and the incidence of parental substance abuse appeared to be 21 per cent for fathers and 7 per cent for mothers. Unfortunately, this study is also typical in that the reliability of information sources is questionable. Nonetheless, the results are compatible with studies in which whole families, or at least one family member other than the patient (84), were directly interviewed. The overall impression is of a disturbed, dislocated family, the father emotionally distant and minimally involved with the patient, the mother centrally powerful, and the drug addiction itself "not only a manifestation of the adolescent's personality disturbance, but symptomatic of a wider family problem" (84). These impressions are further supported by the rare studies that use control groups, both normal and neurotic non-drug-using (19, 84). Investigations have also focused on the drug-using child's perceptions of his parents, as revealed by psychological testing. In particular, perceptions of parental love, hostility, discipline, rejection, and control by various means (viz., anxiety, guilt, withdrawal of relations) have been studied (79, 95), as well as the perception of family "closeness" (96). The families of origin of couples that include a heroin addict have been "reconstructed" through interviews with these hospitalized couples, and this reconstruction was found to illuminate greatly the current dyadic relationship (105). Some attention has also been paid to family composition, with the finding that only children have a different pattern of drug use from those with siblings (65). In an elegantly designed comparison among mothers of drug addicts, mothers of schizophrenics, and mothers of normal adolescents (3), the mothers' "propensity for symbiotic relating" at various stages of their children's development was measured retrospectively, on a "symbiosis" scale based on the concepts of Mahler (68). It was found that all mothers had similar levels of "symbiotic need" during the first five years of the child's life, but that the needs of the "normal" mother subsequently decreased, while those of the other two groups remained significantly higher (the mothers of drug abusers remained the highest). These results tend to confirm the previous impression that the

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relationship between substance abusers and their mothers can be characterized by some kind of excessive closeness. In an earlier, more clinical study of group therapy with three mothers and one father of drug abusers (49), the rejecting aspect of this infantilization is illuminated. A major study, extensive and systematic, by Blum and associates (11) investigated numerous family variables that seem to be predictive of low, middle, and high "drug risk" in adolescents. Family value systems (including religious beliefs), characteristic patterns of interaction, and substance usage seemed of prime importance. However, "high risk" is not synonymous with drug abuse, and the relation between the various risk criteria and actual outcome in terms of drug use and abuse is not dealt with. In general, the product of these lines of investigation is a composite portrait of the substance abuser's family, based either on sociological data (about incidence of separation, divorce rates, class differences) or on generalizations about relationships (dominant mother, absent father). Interesting as these portraits are, they shed little light on our understanding of why any particular individual in any particular family should have a substance abuse problem rather than any of a wide range of other disturbances. We shall now explore in greater depth the clinical-descriptive studies of the family system. Kirschenbaum, Leonoff, and Maliano have delineated characteristic family patterns observed in families with a drug-using member. They take into account the functional relation between the individual and sociocultural systems and the adaptive function of drug use in the face of two dominant stresses in modern American society: "1. Pressure toward cognitive professionalism demanding consistent academic performance at the expense of affect; and 2. Pressure toward psychological numbing by the continual sensory, intellectual and emotional stimulation of modern life" (55, p. 43). Finding the methods of assessing family interaction, as reported in the literature, to be inadequate for the study of the whole interactional pattern, Kirschenbaum et al. used an unstructured clinical interview (87) and Watzlawick's (104) "Structured Family Interview." Ten families were interviewed, observed through one-way mirrors, and videotaped. Two groups of observers (ten adult professionals and students in the mental health field and six untrained adolescents) completed Family Questionnaire forms, which were latter analyzed for family interactional patterns. Drug use was considered functional for the individual in that he protects himself thereby from painful feelings aroused in his family situation (especially protecting his individuality from external intrusion) and provides himself with some form of nurturant or validating experience not available within the family. Eleven family interaction patterns were described. Not only did drug use appear functional for the individual within his family system but it also appeared to serve a stabilizing function for the family by distracting attention from underlying conflicts. Often the drug abuser would protect the coalition between mother and father by attracting onto himself the conflict and pain in the marital relationship, which was frequently characterized by sexual difficulties and problems with intimacy. In seven out of ten of the families, the parents used alcohol to excess, suggesting that this mode of adaptation was tacitly acceptable in the family value system. Overtly, the parents demanded conformity and tolerated little difference or individuality in their children. The fathers assumed the traditionally defined male role, including stereotyped masculine activities, and invalidated their sons' attempts to depart from this model. However, the father's position as strong leader of the family seemed to be a fiction rather than a fact, but a fiction needed and nourished by the "real head of the family," mother. Thus, when one of the fathers began to express his own vulnerability, the equilibrium of the family system was manifestly upset. There is a consistent resemblance between many of these findings and those reported by Blum and associates (11). The latter ranked 101 families on a drug-risk continuum based on the behavior and attitudes of their children. They found that "family variables ... have the major predictive power for drug risk, and the individual variables that do emerge are complementary to the family ones." "Low-risk" families were characterized by a "benevolent dictatorship" structure, diversity of self-expression, the ability to plan and have fun together (55), laughter and teasing, and the maintenance of traditional sexual roles. An important conclusion was that, if the emotional sustenance needed by the child is not forthcoming from the family, he will turn to his peers as a substitute. The distribution of authority in the substance abuser's family is also described by Schwartzman (88, p. 55) from his observation of 21 families of young addicts. "The mother's role as the protector of the addict was reinforced by the father's demand that the addict stop using drugs and get a job or leave home." The fathers were either of the "straw man type," authoritarian but easily controlled by mother, or "distant ... more clearly secondary to the mother in terms of power." It is implied that the son's failure, at work and in life, is encouraged consciously or unconsciously by a weak father who does not want competition and also by the shared assumption that abstinence is physiologically impossible. The marital relationship is characterized by emotional distance except when a period of drug use (actual or suspected by the parents) serves to increase the interaction between the parents. Here again, a system phenomenon may be observed whereby communication among members, an integral part of any system and vital to its functioning, is increased by the behavior of the substance abuser. As Schwartzman points out, "The addict was able to maintain at least some relationship between his parents by his continued drug use. The father was drawn back into the family enough to fight with his wife about the addict and to blame her for the problem ..." (88, p. 157). Howe (51) takes the position that drug abuse is usually a problem for everyone but the abuser. He suggests that "the

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adolescent drug abuser who is in treatment can profitably be seen as a co-therapist in the initial phases.... Whomever he identifies as having a problem should be included in the treatment session.... When the group is assembled, it usually becomes clear that the boy's drug use is, in some significant ways, as much a solution for the family as it has been a problem" (p. 93). He cites a case in which a boy's paint-sniffing served to increase his own power over that of his parents and also to unify them and sidetrack them from their conflicts, "Thus, each time the family started to approach a critical level of anxiety, the boy would be cued to go out and sniff paint and be caught" (p. 96). In this way substance abuse can be seen as a prototype of a "safety-valve" mechanism, "bleeding off" the anxiety that threatens the system's functioning. Howe supports this notion further by observing that "usually when the anxiety is brought to a level that is tolerable for everyone in the system, the cues for delinquent behavior will disappear, and the behavior will cease rather abruptly" (p. 98). The issue of the relationship between drug use and delinquency in the adolescent is an important one. It may be that substance abuse in the context of explicitly antisocial behavior has different determinants from substance abuse as a personal solution within an otherwise socially acceptable lifestyle (including the "counter-cultural" lifestyles, with various degrees of affiliation to the "straight" adult culture, as described by Mulhern [75]). Families that produce "multiple acting-out boys" (73) are frequently characterized by a split between the generations, with a breakdown in communication such that a distinct sibling subsystem develops, which acquires the predominant significance for the children as a socializing agent. However, the conditions that are significant for the pathological development of these boys, for their "blindness to their impingement on others," their "coexistent sense of powerlessness and omnipotence," and the "global inarticulate organization of their experience" (73, p. 126), may not be those that are necessary or sufficient for the development or maintenance of substance abuse. It is important to keep this distinction in mind when studying the families of substance abusers. Within the study of family systems, there is now a body of literature on studies of subsystems of families. In fact, our own work to date has largely been focused on marital subsystems, as will be mentioned later in this paper. The complexity of any interactional context that involves the whole family may be reduced by a focus on dyadic interaction. This is no substitute for a study of the total family, as we imply in our discussion of theoretical assumptions later in this paper, but may usefully complement it. To begin with, an "addictogenic" relationship has been described (65) in terms of a mutual pathological interdependency, comparable to a sadomasochistic relationship. The "addictor" finds relief from emotional tension (principally related to frustration and hostility) by unconsciously encouraging or perpetuating drug addiction in the partner. This paradigm was developed from several case studies of addicted wives of physicians and pharmacists (who originally prescribed the drug for their spouses) but could presumably be extended to other relationships. The empirical investigation of ways in which drugs might render dyadic interaction more satisfying has included studies of the effects of alcohol (23, 92), stimulant drugs (98), and heroin (99). In the first of these the mutual perceptions of alcoholic husbands and their spouses were measured, both when the husband was intoxicated and when he was sober. Changes in perception were examined and compared with the expected changes predicted by the husband and wife. In the latter studies, the abusing individuals' retrospective description of drug-induced functioning was used, and they were asked to characterize their "normal non-drug," "drugged," and "ideal" selves. The perceived effect of the drugs was to enhance interpersonal functioning so that it approached that of the "ideal self."

AREAS FOR FURTHER INVESTIGATION In the light of our review of the literature, we feel that we may now be in a better position to derive some tentative theoretical formulations about the maintenance of substance abuse in the family and to indicate the direction in which we would like to proceed in our own work. Before doing this, we should clarify certain basic theoretical assumptions.

Assumptions A basic assumption is that drug-induced psychological mechanisms alone are insufficient to account for the reinforcement of substance abuse. The importance of context in drug-induced experience is now an accepted phenomenon. Schwartzman describes as the "pharmacological fallacy" the assumption that drugs (defined as "any chemicals that alter the mind") have certain effects irrespective of the context of drug use or the characteristics of the user. Studies of the process often show that a patient's expectations about the drug, confidence in those administering it, and state of emotional arousal determine his response, both psychological and physiological (even to the point of reversing the pharmacological action of the drug (37, 54). Studies of the effects of marijuana (16) and morphine (60) demonstrate that these are strongly influenced by interaction with the experimenter or his accomplice "actor." The latter also found that the majority of normal individuals not experiencing pain find opiates unpleasant and that many who develop physical dependence during medical treatment tend not to resume the use of the drug after withdrawal. It has been observed by the authors and by many experienced clinicians visited by one of the authors in recent months that withdrawal from all the commonly abused drugs can be accomplished with relative ease in a safe, comfortable context. The implication of these observations is that addiction

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cannot be explained adequately in physiological terms or in terms of the intrinsic pleasurable effects of drugs. An explanation must be sought in the interpersonal contexts of drug abuse. It is our impression that family interaction patterns may be of crucial importance in the understanding of the substance abuser. We also assume that the total family system should be taken into account, not merely certain dyadic relationships within it. The term "system" is used in accordance with the theoretical framework of general systems theory (102). Each individual is seen as a subsystem whose functioning relates to the functioning of the family system as a whole. The family system, from another perspective, is itself a subsystem participating in a wider sociocultural system that includes such subsystems as industrial and educational institutions to which different family members belong. It is beyond the scope of this paper to describe and define the full range of basic general systems concepts and their relevance to the individual and family systems: this has been done in a previous paper (56). Only a few of these concepts, directly relevant to the present topic, will be employed here. Traditional science involves teasing out causal relations between past events against a background of independent variables. But connectedness in systems involves the interaction of a great many variables, some of which may well be unknown, and this interaction cannot be reduced to simple two-term relations. The concepts of linear causality and the so-called "pathogenic agent" are replaced by those of multiple and circular causality. The concept of equifinality is fundamental; similar "causes" need not produce similar "results," and similar "results" may well be the product of dissimilar "causes." A minimal change in one part of the system can, by circular processes that amplify deviation, produce a considerable change in the total system. Hence, it will probably prove more fruitful to focus on the necessary and sufficient conditions for the maintenance of substance abuse rather than for its genesis, i.e., on observable processes in the present rather than inferred etiology in the past. Another assumption is that drug use is usually not simply incidental to interactional issues but rather is of central importance in maintaining interactional equilibrium, at least once a chronic pattern of abuse has evolved. Furthermore, a chronic pattern of self-destructive use of substances does not represent a series of discrete events or a sudden discontinuous leap from a category of nonabuse to one of abuse. Rather, many of these events have a common reinforcing set of factors and serve a continuous function. We conceptualize the individual's substance abuse as intimately involved with the level of functioning of the family system. Ferreira (34) has shown how a family may become stuck in a self-perpetuating and self-aggravating cycle in which they exchange less information, know less about each other's wishes and needs, take longer to reach agreements that are less satisfactory to the majority, and become increasingly frustrated, hostile and silent. A replication of Ferreira and Winter's (33) study of family interaction and decision-making (71) confirms that families with a drug-abusing child are stuck in abnormal patterns similar to those found in the other "disturbed" families. In systems terms, we conceive of such a system as stagnant rather than stable. Stability may be related to rigidity or to flexibility (as illustrated by La Fontaine in his fable about the oak tree and the reed). A system is flexible insofar as it can adapt to change without becoming disorganized; otherwise it is rigid. Rigidity is a function of the internal constitution of the system: the more closely knit the organization, the more resistance it offers to the environment and the more permanent it is. The nature of the system's response to the environment can be "tenacious" (resisting change by fending off intrusion: having no effect on the environment), "elastic" (resisting change by working with intrusion in an attempt to restore the status quo) or "self-determinating" (more open to change and tending also to change the environment [32]). The more rigid the system, the more tenacious its response and the more integral it tends to be. The dilemma facing any system is the conflict between complexity (involving growth and, hence, flexibility) and integrality and the need to compromise between these two in order to survive (see Figure 1).

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Figure 1. Schematization of interaction between a system or organization and its environment. The notions of growth, self-determination and actualization of potential are intimately bound up with our intuitive concept of health. Menninger's five orders of dysfunction (72) may be viewed as a progressive retreat from open systems functioning to that of a relatively closed system, narrowing and rigidifying interaction with the environment. Homeostasis is a property of relatively closed systems: open systems achieve "heterostasis" (72) or a "steady state" (Von Bertalanffy, 102), a "perpetually unstable restabilizing" characterized by the progressive moving away from the status quo and, in seeking novelty, change, and unsettled states, "the initiation of some of the very disturbances which the regulatory processes of the organism are patterned to resist" (72). It is in these terms that the well-being of the system must be assessed. There are two complementary aspects  welfare (defined by Trist (30) as "to continue to function well") and development ("to continue to advance"). The former is concerned with the statics of adaptation (stability, as opposed to stagnation), the latter with growth toward higher order states.

Our Previous Work Our own studies of couples with one or both spouses alcoholic suggest that in the intoxicated condition there are recurring, seemingly nonrandom constellations of behaviors, affects, and role changes that are consistently different from those characterizing the couple in their sober state (23, 24). From our preliminary studies of perception of self and of spouse, it seems that there are significant changes in family patterns from sober to intoxicated conditions and that these are highly individualistic for each family (23). Furthermore, it is necessary to study the changing perception of both partners in order to elicit significant changes and to realize that the factors that seem to be relevant to the maintenance of alcohol abuse in any particular couple tend to be unique to that couple rather than generalizable. The implication is that the search for commonalities among such couples may well prove less fruitful than an approach that focuses on the function of substance abuse within each couple or family. The Next Step As a logical next step for us or others to take toward a more systematic understanding of the role of the family in substance abuse, we might propose a study to elicit multiple facets of the family characteristics relevant to the drug use situation. Questions we would ask would include the following: (a) What repetitive patterns, if any, are to be found? (b) Which family members are most significantly involved or affected? (c) What is the impact of these patterns on the abuser? Ideally, to know these family characteristics we must know (a) the behavioral conditions of the drug use situation; (b) the affective conditions of the use situation; (c) the role or self-perception status of each individual under use conditions; (d) each member's perception and interpretation of the "family" under use conditions; and (e) a comparison of (a) through (d) with the same data from the nonuse condition. Testable Hypotheses The use of drugs may be integrated into the family way of life in such a way that the functioning of the family is enhanced

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(e.g., by moderate social use of alcohol) and none of the members experiences detrimental effects. However, if the welfare of the system involves the perpetuation of substance abuse in a member, it must be regarded as a malfunctioning system, since the welfare and development of its members are included in its goals and purposes. One would expect measures of system functioning to demonstrate rigidity, stagnation, lack of spontaneous interaction with the environment, and intolerance of individuality among family members. These might be interpretable as evidence of longstanding pathology in the system (possibly associated with a family myth or the "injunctions and permissions" that rule a child from birth [43]) rather than a short-term crisis with substance abuse as the solution. Contexts of drug use might well enable such a family to keep its interactions with the environment, and within the system, limited, repetitive, and predictable. They may also function to increase the level of communication in the family, thereby fulfilling a system need. More specifically, in terms of the family context of substance use, we would expect to find increased disorganization of the family system prior to the drug-taking. We hypothesize that this increased disorganization would be manifested in one or more of the following ways: 1. increased affect and anxiety, without resolution 2. dyadic conflict 3. blurring of the role relationships within the family 4. changes in self-perceptions Methods exist for the measurement of all four aspects. These will be referred to later. During the drug-taking event, we would expect to find repetitive and stereotyped behavior, as measured by similar techniques. Following the drug-taking, we hypothesize that a decrease in disorganization would be evident, with resolution of conflict and probably with the drug-taker's behavior becoming the focus for previously unresolved feelings of frustration, anger, blame, and contempt. For example, if, as Kirschenbaum (55) suggests, the adolescent's newly developed sexuality becomes a threat to the family myth (that father is omnipotent and the marital relationship mutually satisfactory), we may hypothesize that one of the functions served by drug use is to avoid dealing with the sexual feelings that have aroused so much ambivalence. One might expect drug-taking to be associated with the imminence of sexual feelings in the individual or in a family projective study (42), with misperceptions and confusion in relation to sexual themes. One drawback to these contextual hypotheses is that a finding of lack of support cannot be interpreted in a clearcut productive way. However, we feel that they are still worth investigation. Our review of the literature leads us to the conclusion that the clinical-descriptive approach to these families still has much to contribute toward generating more limited, testable hypotheses. One logical next step could well be a comprehensive assessment of substance use contexts, rather than a more narrow and possibly premature focus on specific aspects. However, from our previous work, we have derived at least one hypothesis that is of more specific nature, to the effect that the particular drug abused is not a significant determinant of the family context of drug use. In investigating this notion, we would be able to draw conclusions from either a positive or negative result.

METHODOLOGY Problems The application of systems principles implies that the assessor is part of the system he is assessing. This has been recognized in clinical work with the family, indeed "joining" the system has been advocated as the only method for diagnosis (74). A crucial problem for research is how far the family's functioning can be assessed from the "outside" and how to allow for the impact of the research context on the system. A related problem is how far a researcher can or should deliberately intervene in the family processes. Are such interventions a way of testing the flexibility of the family? Or do they carry with them even more than a straightforward assessment, the ethical responsibility for providing treatment resources? The problem of what aspects of the family system to focus on may seem overwhelming. Most measures of family interaction were developed to demonstrate differences between the families of schizophrenic children and those of normal children and were often singularly successful in this (e.g., [107]). However, the focus was naturally on those variables considered most relevant to the identified patient's symptoms (thinking and reasoning processes, focusing and sharing of attention, etc.). It may well be that other variables will prove more relevant in investigating substance abuse, and pilot studies will be needed to identify them. Previous studies have sought to reduce the complexity of family interaction by restricting communication to a single modality (e.g., [46]). As Birdwhistell points out in his analysis of interpersonal communication, if we try to record all of the informational single units flowing between two human beings, "the various machines (recording changes in the sound, light, and odor stream) would feed to a master tape some 2,500 to 5,000 bits (and up to 10,000 bits) of information per second .... probably the lifetime efforts of roughly half of the adult population of the United States would be required to sort the units

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deposited on one tape recorded in the course of an hour's interaction between the two subjects" (9, p. 3). In general, the more restricted and artificial the situation (e.g. when communication is restricted to button-pushing), the more quantifiable and reliable the results. There is evidence (77) that the lack of familiar environmental supports in the artificial laboratory situation may allow a clearer picture of family interaction patterns to emerge. Another way to simplify the data is to take the simplest possible measure of the complex situation (e.g., a count of the frequency with which each individual speaks to another [63, 26, 46]). However, a dimension that is so easily measurable may well prove trivial and irrelevant for clinical or theoretical purposes. Also, as Birdwhistell warns, "any discourse analysis, conversational analysis, communicational analysis or interactional analysis which would attend to but one modality  lexical, linguistic or kinesic  must suffer from (or at least be responsible for) the assumption that the other modalities maintain a steady or non-influential state" (9, p. 250). It seems that a compromise is necessary, whereby a Gestalt view of the repetitive patterns and sequences in family interaction may be combined with a close microanalysis of interaction in important contexts. The latter might well be based on Birdwhistell's system, involving lexical, linguistic, and kinesic recording and analysis. The prime importance of videotaped or filmed recording for such analysis is evident. There is some evidence that the subtle changes in interaction to which the family system is responsive may be minimally discernible or even subliminal (82) and may be demonstrable only by such intensive microanalysis. Since the system's response is not the only immediate process in an otherwise inert system but superimposed upon intrinsic, continuous activity, it may prove very difficult to detect. Another methodological problem is whether substance abusers can be considered a homogeneous group for purposes of this type of research or whether there are dimensions (e.g., type of drug used, which member is the abuser, "streetwise" vs. "non-streetwise" abusers) on which to establish a meaningful typology of families. It seems that the issue of typology must await empirical investigation; but from a systems viewpoint, an assumption of non-specificity could be maintained (compare the nonspecific "psychosomatogenic family model" [74, 20] in which a special type of family functioning and the involvement of the child in parental conflict may be related to widely differing psychosomatic symptoms in the child). The issue of control groups poses special problems. It may well be important to compare the families of experimental or casual users with those of substance abusers, since total abstainers may be less "normal" or "healthy" than persons with flexibility to experiment (11). For the sake of brevity, we are not describing the very extensive substance abuse survey that we are conducting at the George Washington University Medical Center. Suffice it to say that a general population survey of drug use and living situation can be one efficient mechanism for identifying relevant substance abusers with intact families and for establishing control groups matched on diverse variables.

CONCLUSION We have attempted to provide a synthesis of current information relevant to our belief that family interaction processes contribute to the maintenance of individual substance abuse. We are obviously at an early stage in our efforts toward understanding substance abuse in terms of family contexts. Our present focus has been on devising ways in which to specify and test hypotheses. Ensuing studies may well come to include therapeutic interventions based on the manipulation of such variables as we have been able to identify in our pilot work. It is possible that the variables we hope to identify in these families will prove to be variables that operate in other families for whom drug abuse is not a problem. There is some evidence that all families go through a regressive phase during the adolescence of an offspring (80), their temporary disturbance paralleling the adolescent's turbulent stage of development. By focusing on drug use episodes, we hope to sample processes that operate continuously in most families but are not readily observable unless highlighted by some affect-laden context. By choosing to study family interaction, we do not intend to deny the importance of factors at other levels (e.g., intrapsychic dynamics or the functional relations between the family and the sociocultural environment). Nonetheless, it seems that the theoretical explanations of addiction, as based on these other levels of inquiry, have not been particularly useful in giving direction to treatment methodology (40). Ultimately, we hope that family-oriented research in this area will bear fruit in the form of valuable applications to therapy.

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