Families of alcohol dependent persons face a number of problems including violence, disruption of family rituals, separation, divorce, inappropriate role models and economic difficulties.
Alcohol dependence does not burst into the family the way a heart attack would; instead it creeps in slowly and silently, until it is finally detected and it is perhaps only then faced by the family. However, by that time it has already left its mark on each family member.
Alcohol dependence is not a condition which once treated can be completely cured. It is a chronic and relapsing condition and always likely to topple the individual back to the same situation of dependence if the individual and his/ her family does not take adequate precautions.
Treating alcohol dependence syndrome (ADS) therefore involves more than just getting the alcohol user to stop using alcohol, it also involves counselling the family with regard to their involvement in the recovery, readapting and rehabilitation of persons with dependence.
Role of family members in the recovery of persons with ADS
The interaction and consequent social reinforcement from within the family environment may often influence alcohol related behaviors. Hence involvement of the significant others is an important component in altering an alcoholic’s drinking habit pattern.
It was found that during the non-verbal interactions, the wives of alcoholics attend more to behaviors associated with alcoholism rather than to non-alcohol related behaviors; this has significant impact on the individual’s drinking.
Research also indicates that involvement of family members by changing the contingencies within the environment can alter an alcoholic’s drinking behavior.
*Professor, Department of Psychiatric Social Work, NIMHANS, Bangalore-560 029
**Asst. Professor of Psychiatric Social Work, Dept. of Psychiatry, Kasturba Medical College, Manipal University, Manipal-576 104
Differential social reinforcement strategies used by spouses and significant persons in the family help in the successful abstinence from alcohol consumption in individuals with alcohol dependence.
It was also found that in intervention programs where spouses were actively involved, the alcoholics tend to have better adherence to treatment and abstinence (Prasadarao, 1990).
Certain family reinforcing consequences of excessive drinking help in maintaining the drinking behaviour among individuals with ADS. One of the social aspects related to drinking – attention from significant others such as family members, friends, etc., influences the alcoholic’s problem drinking.
Hence it is essential to schedule the social and environmental consequences in an individual and his family, so that the alcoholic client receives maximum rewards for abstinence and withdrawal of rewards for drinking and drink related behaviors.
To this effect the spouse of an alcohol dependent individual plays a significant role in reinforcing the adaptive behaviours. Such changes in the family environment help the abstinence behavior and develop adaptive alternative, incompatible behaviors in his natural environment.
The spouse of an alcohol dependent individual can play a significant role in the treatment and in maintaining the abstinence behaviour by a) removing the reinforces for drinking; b) reinforcing the behaviours incompatible with drinking and c) rearranging the environmental cues which set the occasion for drinking in the alcohol dependent individual (Miller, 1976).
In order to influence the abstinence behaviour in the client the family needs to adhere to the following 14 steps. These steps when practiced by the family members can lead to effective abstinence behaviours in the clients with alcohol related problems by achieving the above mentioned goals.
1. Not to suspect the individual:The family members develop a habit of suspecting the client whether he had a drink or not especially when he comes home after the day’s work; some spouses smell the person/dress of the client to check if he has had a drink; though the client comes home dry they tend not to trust him; such behavior of spouse may lead the client to go back for drinks due to mistrust; do not suspect the client especially with regard to his abstinence; stop smelling his clothes, checking his belongings, etc., especially when the client comes home late.
2. Develop trust in the individual:Usually due to the chronic alcoholism, the family members tend to lose trust on the client’s role in the familial and occupational issues and his financial accountability.
When once the client attains abstinence following intervention it is essential to trust him especially when he says that he abstained from drinks. Support him in a planned and graded fashion in clearance of his debts
3. Do not discuss the individual’s previous drinking problems and consequences with others: The family members frequently tend to discuss the client’s habit of excessive drinking, consequences experienced by the client and family members due to alcohol, with the visitors, friends and relatives at home.
They tend to criticize the client and ridicule him in front of others. Following abstinence, do not discuss any of the previous drinking related behaviours pertaining to the client with visitors, relatives and friends at home.
4. Eliminate the alcohol related cues from the home environment:Generally, the client with chronic alcoholism tends to keep the glasses and alcohol bottles at home. He stores drinks at home, at specific places such as refrigerator, shelves, corners, under the cot etc.
Following abstinence if the client is frequently exposed to drinks and the alcohol related stimuli especially during the initial phase of abstinence following treatment, it may trigger craving for drinks.
Hence it is essential to remove these drinking related cues such as alcohol glasses, and alcohol bottles. Storing alcohol at home and serving guests with alcohol are not advisable.
5. Reinforce the Individual’s sobriety: The spouse, family members, friends and well wishers must appreciate and reward the client’s abstinence behaviour. Consistent reinforcement from all the significant persons of an individual with alcohol dependence always helps in maintaining the abstinence.
6. Express Happiness of Abstinence: The spouse and other family members must express their happiness over client’s sobriety and changes in his activities following his abstinence.
The spouse and family must provide the client with feedback indicating the changes occurred in the family following the client’s abstinence. The spouse must indicate to him that there is a change in the client’s behaviour, and the children’s behaviour too; e.g., now the children feel happy; there is a change in the emotional atmosphere at home; interaction among family members has improved, the client takes care of children and other family members, the client attends to his work regularly, etc.
8. Encourage alternative pleasurable activities: Encourage the client to involve in various alternative activities such as developing certain hobbies at home, going for marketing, teaching children, etc., especially during the time when previously the client used to spend in drinking.
The spouse can also encourage the client to resume previous interests in various activities which he used to involve before the onset of alcohol abuse.
9. Deal with interpersonal problems in the family: During the drinking period, the alcoholic client tends to develop interpersonal difficulties with family members and other relatives.
These individuals with whom the client has had interpersonal difficulties and conflicts should be advised not to probe into those aspects again. These individuals must also be requested to co-operate with the client, so as to reinforce his abstinence and change in his behaviour.
10. Improve communication at home and avoid criticism: Most often the individuals with alcohol dependence tend to develop disturbed communication patterns with family members during their excessive alcohol intake.
Since most part of the day they are preoccupied with alcohol and are in an intoxicated state, they stop communicating in an adaptive manner with the family members. Moreover, the family members develop a specific pattern of communication with an alcoholic client and they interact with him only by criticizing and ridiculing.
Hence the family members must once again initiate adaptive communication with the client without criticizing and ridiculing him and interact with him in a positive manner, to facilitate developing normal patterns of communication in the client. Family members need to communicate uniformly with the alcohol dependent individual. Avoid addressing the client in disrespectful manner.
11. Inform his friends, other family members and relatives about his abstinence: Relapse of drinking may be triggered by the pressure from peer group and significant persons in the environment of the recovering individual.
The spouse must urge/ warn these individuals (e.g., friends, colleagues and relatives) in the client’s immediate environment with drinking habit and with potential to pressurize the client for taking drinks.
The spouse and other family members must firmly indicate to these individuals not to discuss about alcohol related issues with the client; not to offer him drinks; and not to invite him to situations where drinking is involved.
12. Identify risk factors for relapse: Certain potential risk factors such as meeting with specific situations, stressors at home or at work situation, crisis and conflicts, and certain emotional states may trigger a relapse in an abstaining individual.
The spouse must identify these situations, especially the factors which previously used to trigger alcohol intake in the client and take necessary steps so that the client would not go for a drink. Whenever the client experiences such potential risk situations, the significant others must bring the client to the therapist, if necessary, so that a potential relapse can be prevented by handling such triggering factors.
13. Identify the behaviour that may indicate a potential relapse: The spouse must identify any change in the individual’s behaviour that may indicate a potential relapse.
These factors include restlessness, boredom, frequent spells of anger, frequent returning home late, spending large sums of money, etc. During these situations the spouse must be vigilant and bring the client to the therapist in order to prevent/handle the lapse/relapse in the individual by positively responding to the situation.
14. Ensure periodic follow-up:To continue longer periods of abstinence it is essential to maintain a consistent follow-up with the treating professionals. Frequently, the individuals with alcohol dependence and their family members tend to discontinue meeting the treating professionals once the individual achieves a short period of abstinence.
Maintaining follow-up with the treating professionals can identify and evaluate any possible risk factors for relapse and help the client accordingly in order to prevent such potential laps and relapsing situations. Hence, the spouse and family must encourage and bring the client consistently for periodic follow up with the professionals.
Conclusion: Usually, families bring the person with ADS to a treatment centre with a proposition of “He is drinking, we brought him and you cure him”. When a client in a treatment centre moves from a healthy, protecting, supporting environment to a the same old vulnerable, unsupportive, risky terrains, family involvement as depicted in the fourteen steps not only beneficial for the individual with the alcohol dependence syndrome in terms of recovery but also through social work intervention; the impact of alcohol dependence on family can be reduced by involving them in the treatment, recovery, family readapting, social rehabilitation and community reintegration process by strengthening family interaction pattern and thereby improving the quality of marital and family life of the persons with alcohol dependence.
Checklist for Family Involvement in Recovery & Rehabilitation Process of Persons with Alcohol Dependence
1 We help him financially to repay debt or otherwise
2 We help him to retain/ get a job
3 We help him to manage his craving
4 We help him to handle peer pressure
5 We assist him to celebrate festival/ holiday without alcohol:
6 We assist him to grow spiritually
7 We assist him to maintain regular follow-up
8 We assist him to develop alternate means of pleasurable activities
9 Were inforced him that he has ability to abstain
10 We trusted him when he had not drunk
11 We made efforts to spend more time with him
12 We assist him to overcome loneliness/ boredom
13 We tried to keep home environment peaceful and happy
14. Any other
Scoring: Yes=1, No=0 (Higher scores indicates high level of family involvement in recovery process)
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