Drug and Alcohol Review (1994) 13, 371-374

EDITORIAL

Alcohol and other drugs--a family business

This special issue arises from the designation of 1994 as the International Year of the Family. While debates continue about the nature of the family, with some suggesting that the family is moribund in western, industrial society, families remain an endur- ing social institution. We are all products of a family. Through our families we are connected to the memories of our ancestors and the hopes of our children.

Despite the role and ubiquity of the family, it is a surprisingly slippery institution to define. Some an- thropologists argue that there is no single property of families that can be applied across all cultures, expect for the biological tie between mother and child. This definitional problem is compounded in westernized countries by the fragility and instability of the family constellation.

In Australia today almost all of us will either be divorced ourselves or have a relative or close friend who is divorced. Current figures suggest that 43o/6 of marriages will end in divorce or separation within the next 30 years [1] and yet Australian rates are not particularly high by western standards. In the United States, for example, this figure is around 55%; in Denmark it is 49% and in England and Wales roughly 42% of marriages disintegrate.

Thus, the idea with which many of our generation grew up, that separation or divorce are exceptional, even shameful, is simply not sustainable today.

The broadening definition of the family suggests that the forms families take will change the nature of how we think of this institution even more dramati- cally over the next 25 years. While there has been widespread appreciation of such family forms as gay partnerships for some time, the reference to gay couples as families in Australian politicians' public speeches is more recent. It was not surprising to hear

a generally progressive politician suggest that family leave to allow workers to care for sick family mem- bers should be a right under industrial legislation, and include gay partnerships. I t was more surprising to hear a conservative political leader announce that all future policies developed by his government would be accompanied by a family impact statement. He went on explicitly to include gay families within his definition of the family as "people living together and caring for each other" [2]. This announcement serves as one indication of the momentum of changes in acceptance.

These statements are indicative of the re-emerg- ence of the family as a focus of political contest and all major parties are busy preparing family focused policy platforms for the next Australian federal elec- tion. A possible reason for the upsurge in interest in the family is the belief that in a growing economy, with falling unemployment, the political focus will shift from a preoccupation with economic manage- ment to questions of living standards. Other changes, such as labour market participation, have altered the nature of employment in Australia during the past 20 years impacting upon the roles and relationships within families. The family emerges as a key institution in society, undergoing change and responsive to social, economic, political, demo- graphic and cultural forces.

Families have become a part of the established literature in the alcohol and drug arena. The focus varies over time and has included the family in the aetiology of alcohol and other drug problems, the effects of a heavy drinker or drug user on the family and family involvement in treatment.

The emphasis has traditionally been on the patho- logical individual user, or the "pathological" family. While these themes can still be found, we see a

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broadening of interest in families and ways of writ- ing about them. Interest in primary and secondary prevention of alcohol and drug problems has con- tributed to attempts to not only identify those at-risk of developing alcohol and other drug prob- lems, but also to develop interventions which might support behaviour change at an earlier point in a drinking or drug-taking career. Many of these public health interests focus directly or indirectly on the family.

Families are where most people have their first introduction to drug use; whether this be through medications, the first sip of alcohol, the initial so- cialization in use of traditional drugs, the possible exposure of the foetus to drugs that a mother con- sumes or exposure to passive smoking.

The drugs that we use, the way that we use them and the consequences of their use are likely to be determined in large part by our family origins. A relatively uncontested finding from research suggests that one of the strongest predictors of alcohol and drug problems is to have come from a family where these problems have been experienced. This lies behind the interest in the nature-nurture debates in

t h i s area. The Hopper paper is included in this volume to

reflect on the current state and utility of the research and writing about genetic contributions at this time, rather than to engage in the genetic debate per se. A more useful focus might be to attend to the criteria used in deciding on the appropriateness of screening and other potential applications of this knowledge and it is here that little research has yet been done.

Until now, the efforts at primary prevention, in- cluding policy and legislative attention as well as more direct educational and media campaigns, have been aimed primarily at shifting broad cultural norms regarding the use of licit drugs. Whether the family's contribution is biological or through social- ization, little has been done to identify "at-risk families" and explore novel interventions which might prevent subsequent generational alcohol and drug problems. While modification of parental drinking or drug-taking is an obvious target one might, in addition, usefully consider direct prevent- ative interventions aimed at the children of these primary clients.

It seems certain that changing forms of the family and shifting roles as well as socio-economic circum- stances are linked to altered patterns of drug use. Drawing from observations of North America,

Straussner's paper in this volume offers two dimen- sions of analysis in describing the impact of drug use in the family: the era or age/stage of the user(s) and the specific drug(s) that are being used.

The more careful matching of interventions to specific family scenarios might provide some way forward. Toumbourou, while presenting a review of family involvement in treatment for illicit drug users, introduces the possibility of broadening treatment goals. He suggests the possible inclusion of primary prevention aims for family members other than the identified drug user.

The interest in earlier and more successful inter- ventions lies behind Orford's paper, which serves to introduce perhaps the strongest current area of writ- ing and research on drugs and alcohol and the family; that of working with, or analysing, those who live with the drinker or drug user.

Few would argue with the proposition that a// members of a family, where one or more members is drinking or using other drugs heavily or outside the usual cultural norms (and even sometimes within them), will be affected to some degree and many are likely to seek assistance. Orford combines a typology of coping behaviours with a discussion of how gen- eralist workers in primary health care might use this to assist relatives cope effectively with family prob- lems, while Barber and Crisp outline an approach to working with partners of problem drinkers that offers a practical guide to reducing the harm to the family by putting pressure on the drinker to change.

On the basis of her research in Finland, Holmila suggests broadening the notion of the "significant other" (usually perceived as a woman) to include male extended family members, friends and col- leagues of problem drinkers. She urges an examin- ation of how significant others view themselves rather than the imposition of labels.

WattS, Bush and Wilson offer a "stress and cop- ing" framework as an alternative approach which is applicable to both the research and treatment arenas. They argue for a shift from the traditional patholo- gizing of families to a more functional understand- ing of how and why families stay together; the choices that partners make and ways in which famil- ies might be supported to counter the potentially dysfunctional aspects of problem drinking.

A number of contributors to this volume, includ- ing Holmila, Watts et aZ and Hands and Dear, address the long history of identifying the drinker's spouse (usually his wife) as, variously, the victim or

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the villain. In these papers critical reviews are made of the emphasis in previous research on pathologiz- ing the family, and particularly the spouse, of the drinker or drug taker, which culminated in the emergence of notions of co-dependence during the mid 1980s. This particular approach spawned a new family-focused industry, or at least a re-focusing on symbiotic partner relationships.

Writing on partner relationships has not been confined to the academic literature. There has been a plethora of items in the popular press especially on "co-dependency". Much of this has been anecdotal, or at best descriptive and some tends to the polemi- cal or accusatory. It is hoped that the tide has turned on co-dependency and the Hands and Dear paper offers a timely critique of this framework, helping to shift the focus away from a new era of pathologizing and labelling partners, an historic practice which is to be deplored.

Labels are not always ascribed by others in this field. The strong tradition of self-declaration as a pathway to sobriety was enshrined in the traditions of Alcoholics Anonymous and other self-help groups that have subsequently emerged. Over the past decade, other family members have sought specific identity in the emergence of self-named groups such as "Adult Children Of Alcoholics".

Other family identifier labels have been taken on for advocacy and political or prevention purposes. "Mothers Against Drink Driving", in North Amer- ica, perhaps represents a link between public health concerns focusing on the harms associated with alcohol consumption and the more fundamental and emotive interests of parents in the fate of their offspring. Transposed, this is mirrored in the finding that one of the concerns about alcohol-related harm most often raised by youth is their experience of being passengers in vehicles driven by adults who have been drinking [3].

This issue contains papers which were deliberately selected to provide alternate theoretical orientations, epistemologies and loci to reflect the diversity and potential debate that might be generated in our field. There are losses in having consensus and it seems the arena of drugs and the family could do with some energizing debate or discourse, which might be facilitated by importing concepts and methods of inquiry from elsewhere. This can help to sharpen traditional analysis as well as provide new under- standings.

In what might be termed "Orford's Reminder",

Orford [4] drew attention to the potential for theor- etical isolation in the alcohol and drug field in a paper on the family some 20 years ago. He examined the findings of an era of studies on alcohol-affected families in the context of general studies of troubled families and pointed out that the features which had been ascribed to alcohol were features found in other troubled families where no problem drinking was present. The need to stay in touch with research and theoretical developments in parallel and foundation disciplines needs to be remembered.

While this field is considerably more sophisticated and populated than it was 20 years ago, the ongoing tendency for theoretical and practical enclaving re- mains. There are contradictions inherent in bringing together professionals from different traditions and backgrounds. To accomplish such a task means first having to generate some mutual respect, a common language and shared purpose, even if these are gen- erated for different motives.

These difficulties, which are apparent in the arena where service systems interface with each other and the family, are addressed in the paper from Scott and Campbell. In an effort to introduce an alternate perspective this paper comes from the world of child welfare rather than that of the alcohol and drug practitioner. The brief commentary offered by Mc- Gregor, from alcohol and drug services, highlights this difference. Coming from an alcohol and drug service, her refreshing honesty about the primary focus on the individual (potentially to the detriment of other family members, unwittingly even including children) provides stark evidence to support the view of potential impediments to cohesive work with families in this environment.

Clearly, not all drug use within families is prob- lematic or dysfunctional. In fact, it can be suggested that much drug use is functional and adaptive. The difference between the language used to describe the drinking of alcohol, for example, depending on whether the commentator views it as a positive, pleasurable, relaxing and convivial activity or a dis- ruptive, irresponsible, dangerous or harmful act, is profound. In addition, the context in which the drinking takes place and the identity, gender, age and stares of the drinkers affects one's view. It is necessary to recognize the social construction of the way we understand both families and the use of drugs.

The use of a range of drugs in response to stress and structural disadvantage might be functional. It is

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difficult to argue with an unemployed young person who suggests that the use of some drugs is an appropriate response or adaptation to their social position and, possibly, psychological state. This is not a new idea. Writers have been pointing out the functional elements of drug and alcohol use for some time. After all, the substances we use are usually quick-acting, comparatively inexpensive, readily ac- cessible and non-demanding; and far easier to get than solace from other sources (either personal or institutional). The effort to analyse the meaning one might make of these alternate views of the use of alcohol within the family are raised in the theo- retical, exploratory paper introducing us to post- structural analysis and a focus on discourse.

This contribution from Reelde, an historian out- side the specialist drug and alcohol discipline, has been deliberately included to stimulate alternative ways of conceptualizing our territory. While this paper might require some mental stretching to translate the concepts into the alcohol and drug domain, ideas from the outside might refresh our field and connect us to significant theorizing in foundation disciplines.

In the process of developing this special issue of Drug andAlcohol Review, it has become evident that much is written and spoken about the necessity of attending to the needs of families in research, inter- vention and treatment in the drug and alcohol arena. However, it is also apparent that in all these do- mains the practice does not match the discourse. Thorough, innovative research relating to families is limited. While practitioners acknowledge the im- portance of the family in the origin of some sub- stance problems and the probability of the impact of an individual's drug use on other family members, little real attention is paid to families in most specialist treatment services. The economic impera- tives driving programme development in most in- dustrialized countries currently appear to be antithetical to engaging families in these domains.

As the considerable rhetoric has been increasing for some decades, it is timely perhaps to question the seriousness of our commitment to the family in this area. Do we accept that alcohol and drug use and the problems associated with this use are really family business?

If we do, the challenge is first how to capture (in whatever form and through whatever frame) the strength of the energy, enthusiasm and interest that exists in communities for families and family-related concerns. Secondly, how do we then connect this with research-based knowledge and inquiry regard- ing the way in which families contribute to the drug-using patterns of their members? Thirdly, how do we encourage and facilitate the potential role of families in a range of preventative interventions (from primary health promotion to involvement in later stage drinking/drug-taking career treatments)?

I f alcohol and drugs are indeed to be acknowl- edged as family business, let us remain open to new ways of seeing the world and, more immediately, work to maintain the possibility of family relevant services: whatever form those families take. Keeping in mind the need for application and relevance, this is a field ripe for creative new ideas!

MARGARET HAMILTON

Associate Professor, Drug & Alcohol Research and Teaching Unit, Department of Public Health & Community Medicine, Universi~ of Melbourne, 200 Berkeley Street, Carlton 3053, Australia

JAMES G. BARBER

School of Social Administration and Social Work, Flinders University of South Australia, GPO Box 2100, Adelaide 5001, Australia

CATHY BANWELL

Research Fellow, Department of Public Health & Community Medicine, University of Melbourne, 200 Berkeley Street, Carlton 3053, Australia

References

[1] Australian Bureau of Statistics, Australian Social Trends 1994. ABS Cat. no. 4102.0, Commonwealth of Australia. AGPS, 1994.

[2] Brown Dean. Announcement while interviewed for ABC news in mid August 1994.

[3] Munroe G. Youth alcohol and community project. Substance: Australian Drug Foundation, 1993.

[4] Orford J. Alcoholism and marriage: an argument against specialism. J Stud Alc 1975;36:1537-63.