Διερεύνηση του οικογενειακού συστήματος χρηστών εξαρτησιογόνων ουσιών και ατόμων με σχιζοφρενική ψύχωση
Authors: Pomini Mariavaleria 
Published: September 2021

Introduction: Stressful life events, poor parental bonding, rejecting attitudes andnegative affective style in the family have been showed to influence the course ofmental disorders. However, in the field of substance abuse and particularly heroinaddiction, these factors have been not adequately studied yet, or findings are stillinsufficient.The aim of this study was to investigate family factors which might contribute to thedevelopment of heroin addiction. For this purpose, a sample of heroin addicts’families was compared with a sample of families with an adult child diagnosed withschizophrenia and a sample of non- clinical families. More specifically, the studyfocused on the following factors:1. The stressful events in the family life cycle as well as in the parents’ families oforigin,2. The characteristics and quality of the parental bond, as perceived by theaddicted person, or the person with a diagnosis of schizophrenia, during the courseof their childhood and adolescence, and as every parent had experienced inrelation to their respective parents.3. The attitudes of rejection from the parents towards the person with addiction orthe person diagnosed with schizophrenia. These attitudes are regarded asindicators of the family’s emotional atmosphere that developed after the onset ofthe problem.Clinical subjects and methodology: The total sample of this study included 200subjects from 84 families. Of the subjects, 84 were in the position of adult child,male, 20-30 years of age, while 116 were parents: 74 mothers and 42 fathers. Thefirst sample included 40 heroin addicts, 20-30 years of age, with a history of addictionfrom one to ten years, and 57 parents, of whom 37 were mothers and 20 fathers. Allthe subjects had addressed for help at the “Athina” Program, an outpatient drug free psychotherapeutic facility for alcohol and drug abuse which belongs to the 1stPsychiatric Clinic of the University of Athens and OKANA. All these subjectsfulfilled the diagnostic criteria of heroin addiction according to both DSM-IV andICD-10. The second clinical sample included 17 subjects with a diagnosis ofschizophrenia and 22 parents, of whom 15 were mothers and 7 fathers. All subjectswere male, 20-30 years of age and the duration of illness was from one to ten years.All of them were receiving regular medical treatment at the Outpatient Clinic or theDay Hospital of the 1st Psychiatric Clinic of the University of Athens- EginitionHospital during the time span the interviews where performed. The diagnosticprocess had been completed in the context of their psychiatric treatment, based on thediagnostic criteria of DSM-IV, and all subjects fulfilled the criteria for a diagnosis ofschizophrenia. The third sample consisted of healthy young adult male controls andincluded 27 subjects, 20-30 years of age, and 35 parents, of which 22 were mothersand 15 fathers. For the estimation of substance use in the present, as well as in thepast, the questionnaire for the assessment of use and abuse of legal and illegalpsychotropic substances (Patterns of Abuse) of the World Health Organization wasutilized. For the collection of the socio-demographic data and the transgenerationalfamily history, a semi-structured interview was used, which had been created byTomaras and Pomini for the needs of the Family and Couple Therapy Unit of the 1stPsychiatric Clinic of the University of Athens- Eginition Hospital. Additionally, forthe listing of stressful life events in the family, a brief scale was used, which wasdeveloped by the author for the needs of the present study. The Parental BondingInstruments was translated and adapted into Greek for the assessment of the parentalbond as perceived from the subject, pertaining to his childhood and adolescence, aswell from his parents regarding their respective parents. Lastly, the Patient RejectionScale was also translated and adapted into Greek for the evaluation of the parents’negative attitudes towards the child.Results. 1. The samples consisted of male young adults with a mean age of 25.1 years(± 3.1) and at least one of their parents. All were Greek, residents of Athens or otherneighboring municipalities of Attica. Hence, all three samples were homogeneous inreference to age, family situation (almost all were unmarried and living with theirpaternal family), working situation (almost half were employed), number of siblingsin the family and order of birth. The severity of the clinical picture of the two clinicalsamples was similar: The mean duration of heroin use was six years and almost all addicts reported injected use, while the subjects diagnosed with schizophrenia had amean duration of illness of five years.2. The heroin addicts differentiated at the academic level, having statistically lowerlevel of education from the control group.3. The percentage of one-parent families wasn’t significantly different in the threegroups. Over the one third of the heroin addicts or more (37,5%) grew up and/or livedwithout their father, either because he had prematurely died (15%), either because theparents were separated or divorced (22.5%). Additionally, a significantly higherpercentage of heroin addicts’ fathers (44.4%) presented a current or past psychiatricproblem, more frequently than in the control group. However, this percentage did notdiffer in the group of subjects diagnosed with schizophrenia compared to the controls.4. The comparison of stressful life events in the family between the three groups ofthe sample showed that both the heroin addicts and the patients with a diagnosis ofschizophrenia had lived in their childhood and/or adolescence stressful life eventssignificantly more often than what happened to the subjects of the control group:72.5% of the heroin addicts’ families and 82.3% of the families of the patientsdiagnosed with schizophrenia reported at least one stressful event in the nuclearfamily, compared to 33.3% of the control group’s families. Additionally, the total ofstressful life events in the nuclear family was significantly higher both within theheroin addicts and the subjects diagnosed with schizophrenia in comparison to thecontrols. In contrast, there were no significant differences regarding the totalpercentage of stressful life events in the parents’ families of origin between the threegroups. The comparison of different categories of stressful life events in the familybetween all three groups of the sample did not show statistically significantdifferences, either those pertained to the nuclear family, or the families of origin,except the fathers’ psychiatric history in the group of heroin addicts, which wassignificantly higher, as was aforementioned. In total, the families of the subjectsdiagnosed with schizophrenia reported totally more stressful life events in comparisonwith the other two groups. This result showed the higher degree of stress which seemsthese families had to deal with.5. The evaluation of the characteristics and the quality of the parental bonding in thefamily showed that the heroin addicts and the subject diagnosed with schizophreniareported significantly less care by their mothers as well as by their fathers, incomparison to the subjects of the control group. Furthermore, heroin addicts andsubjects diagnosed with schizophrenia reported to have received significantly more overprotection/control both by their mothers and their fathers, in comparison to thecontrol group. In contrast, the degree of care and the degree of overprotection did notdiffer between the two clinical groups. Therefore, the profile of the parent/childrelationship was significantly poorer in the families of the heroin addicts as well as ofthe subjects diagnosed with schizophrenia, in comparison to the healthy families.Comparing the three groups of the sample in regards to the level of care perceivedfrom the mother, with the level of care perceived from the fathers, it resulted thatheroin addicts reported significantly more care from their mothers than from theirfathers.6. The comparison of the categories of the parental bonding between the three groupsshowed that fewer families of heroin addicts (41.2%) were placed in the category of“optimal parenting”, comparatively to the 47.1% of the families of the subjectsdiagnosed with schizophrenia and the 65.4% of the families of the control group.Also, more families of heroin addicts were placed in the category of “parentalneglectful” compared to the other two groups of the present study, while morefamilies of the subjects diagnosed with schizophrenia were placed in the category“affectionless control”.7. Both in the control group, as well as in the group of subjects diagnosed withschizophrenia, the participants received similar care and overprotection from theirparents compared to those their parents had received from their own parents. Theexception was the group of heroin addicts, who received more maternal care than theirmothers had received from their own mothers, but less maternal care than their fathershad received from their own mothers. Also, both the subjects diagnosed withschizophrenia and the heroin addicts received more overprotection/control from theirmothers than their fathers had received from their own mothers.8. The multifactorial analysis showed that the correlation of the “overprotection” scalewhich pertained to the patients’ fathers and the “overprotection” scale whichpertained to the fathers’ fathers was stronger in the group of subjects diagnosed withschizophrenia in comparison to the control group. So, the more overprotection afather had received from his father, the more overprotective and controlling he wastowards his child. Also, within the group of subjects diagnosed with schizophreniathere was a significant correlation between the care perceived by the mothers and thecare that mothers had received from their own mothers. So, the less caring thematernal grandmother was, the less caring the mother was towards her child too.Contrasting, for the group of heroin addicts the multifactorial analysis showed a correlation of the “care” scale which pertained to the addicts’ mothers with the “care”scale pertained to the fathers’ mothers. So, the lack of care from mothers reported bythe heroin addicts was correlated to the lack of care that their fathers had receivedfrom their own mothers. Also in the same group, regarding to the “overprotection”scale, there was a significant correlation between the fathers and the mothers’ fathers.So, in the heroin addicts’ families, it seems that a model of mother/child bondingregarding the perceived level of care was similar to the model which the fatherreported in relation to his own mother, while the degree of overprotection/control thatthe child perceived from the father was correlated to that which the mother hadexperienced in the relationship with her father.9. The Patient Rejection Scale was used for the measurement of the rejecting andnegative attitudes towards the patient in the family. The results of the present studyshowed that the degree of rejection both from the mother and the father wassignificantly higher in the families of the heroin addicts as well as the subjects with adiagnosis of schizophrenia in comparison with the families of the control group.Also, the degree of rejection from the father towards the child with heroin addictionwas significantly higher even from the degree of rejection from the father in the groupof the subjects with a diagnosis of schizophrenia, while the degree of rejection fromthe mother was higher and approached the significance. Also, the correlation betweenthe scores of the mothers and the fathers separately for every group showed that inboth the clinical groups the more rejecting one parent was, the more rejecting theother one was. Contrarily, in the control group the rejection from one parent wasindependent from the rejection of the other.10. The correlation between the Parental Bonding Instrument and the PatientRejection Scale showed that in the group of heroin addicts the mothers that werereported as less caring were the ones that demonstrated more rejecting and negativeattitudes. In the families with a rejecting father, the care that both parents offered waspoorer and, in contrast, the pressure of overprotection and control towards the childwas higher from both parents.11. The multifactorial correlations of the total of the stressful life events with therejection from the parents and the dimensions of care and overprotection/control inall three groups showed no significance. Only the correlation of the total stressful lifeevents with showed that in families that reported a history of more stressful lifeevents, there was less care from the father. Conclusion. In total, the families of the two clinical groups showed that they wereexposed to stressful life events to a significantly greater degree in comparison to thefamilies of the control group. This means that both the heroin users and the patientswith a diagnosis of schizophrenia lived through, during their childhood and/oradolescence, situations that caused psychological stress more often than the subjectsof the control group. This confirmed similar findings from previous studies that wereconducted abroad, while it is a new finding pertaining to the Greek population ofheroin addicts. The exposure to stressful life events during childhood and/oradolescence has been showed to be related to the development of psychiatric disorderor substance abuse in adulthood, based on the cause-effect model of “stress -vulnerability”, especially when life events include the mental illness of a parent. Thisfinding arose significantly more frequent in the group of heroin addicts of the presentstudy, and less for the group of patients with a diagnosis of schizophrenia, which wasunexpected, due to the higher influence of genetic factors in psychotic disorders. Inthe families of heroin addicts it was also observed a higher percentage of single-parentfamilies, either due to the early loss of the father, or parental divorce, in comparisonto the other two groups. The lack of paternal figure has been reported to be a riskfactor related to the development of depression, substance use and other high riskbehaviors. Therefore, the families of heroin addicts showed to be more exposed todysfunctional patterns, in relation to their structure and the presence of risk factors.The evaluation of stressful life events in the parents’ families of origin represented anew finding, for the Greek as well as the international literature in the field ofsubstance addiction. The sum of the stressful life events in the nuclear family and inthe families of origin showed to be significantly higher in the group with patients witha diagnosis of schizophrenia, compared to the other two groups. It could be observedthat, in the families of patients with a diagnosis of schizophrenia, the exposure tostressful life events started from the previous generation and tends to be repeated inthe next. Contrarily, in the families of heroin addicts the presence of stressful lifeevents was assessed mainly in the present nuclear family.The families of heroin addicts and the patients with a diagnosis of schizophrenia thatparticipated in the present study, showed a profile of parent/child bond clearly poorerand more dysfunctional in comparison to the healthy families. The findings of thepresent study agreed in a great degree with those of previous studies from abroad andconfirmed the clinical observations that heroin addicts belong more often to familieswith a dysfunctional profile of parental bonding, characterized both by the lack of parental care and high overprotection/control, mostly on behalf of the mother. Thefather, when not absent, was often described as emotionally distant, while the motherdisplayed excessive emotional involvement that was expressed through overprotectingand excessive control. Also, the findings of the present study support therepetitiveness of the model of parental bonding from one generation to the next,especially in the two clinical samples. Especially in the group of heroin addicts, thefindings of the present study showed a “cross-directional” influence of the parentalbonding model from one generation to the next, which was related to the “choice” ofspouse on behalf of the parents of the heroin users. This finding is connected toprevious clinical observations supporting a trigenerational model of the developmentof heroin dependency, based on the hypothesis of transmission of emotionaldeficiency and the non-recognition of the psychic wound, from the previousgeneration to the next, of which the choice of the parental couple is integral part. Thelack of care and the excessive overprotection/control appeared to be positively relatedto the rejecting and negative attitudes of the parents towards the heroin addicts and thepatients with schizophrenia. The findings showed that the degree of rejection fromthe mother as well as from the father towards the heroin addicts was significantlyhigher than the degree of rejection in the control group, but also in the group ofpatients with a diagnosis of schizophrenia. Also, the negative attitudes of one of theparents seemed to enhance the negative attitudes of the other parent in the two clinicalgroups. These particular findings were not the expected ones and show to be relevant,given the impressive lack of studies in the field of expressed emotions and affectivestyle in families with a substance-dependent member and especially with a memberdependent on heroin.In summary, in spite of its limitations, the findings of the present study showed theimportance of negative family factors in the course of heroin addiction, as well as inother severe mental disorders like schizophrenia. Several of these factors arecorrelated to the frequency of stressful life events in the addict’s family, thedysfunctional parental bond characterized by lack of care and excessiveoverprotection/control, as well as the presence of rejection and hostility on behalf ofthe parents. These findings set important issues regarding the interventions in thefield of both prevention and therapeutic treatment of heroin dependency, underliningthe necessity of involving the addict’s family in the therapeutic process, but also theimportance of preventive and counseling interventions to families that present higherfactors of psychosocial stress.