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Role reversals in families of substance misusers: a transgenerational phenomenon.

Fifty adult methadone maintained opiate misusers were seen with their spouse and/or family of origin in outpatient therapy as part of a Veterans Administration Research project supported by NIDA. Family treatment was offered in an attempt to improve and enhance family relationships/social supports and to aid in the decrease or cessation of drug use. In this study, 42 of the 50 patients had parents who were substance misusers. The subjects were evaluated by constructing a Three-Generational Family Tree to define and clarify the nature of problems across the generations. Success or failure was measured by the Addiction Severity Index (ASI) which assessed drug use, problems with family, health, social relationships, legal difficulties, and employment as well as psychiatric symptoms. A recurrent problem of the "absent father" was identified across both generations studied. Thirty of the 50 opiate misusing men had absent fathers (usually due to alcohol or other drug misuse) and 27 of these 30 became absent fathers (also usually due to substance misuse) when they had children of their own. The absence of a father produced major developmental problems seen in these families. Particularly important was the "Parentified Child," forced to prematurely assume adult responsibilities. This age inappropriate role assumption was common in both the patients and their children, and was seen as a contributor to the initiation of drug misuse. A structured clinical intervention is described using the three-generational family tree to bring out these relationship issues, followed by supportive family therapy to restructure wounded family relationships from the family of origin and to bring about appropriate role expectations in the marital families. The findings suggest an improvement in legal difficulties, drug use, and psychiatric symptoms.