Objective 8

To describe what care is needed for family members affected by a relatives substance use disorder and how to make a viable referral for them.

A few years ago a Gallop Poll on alcohol related problems in the family found that more than a quarter of the American population reported that they had a close family member who was abusing alcohol or some other drug. This is a very large number. A quarter of the American population is more than 60 million people. You will certainly meet many of these people in your practice.

Most of these people are dealing appropriately with their family issues, but some need assistance. The challenge is to identify these people among your patient population.

The first place to start is with the family members of a patient whom you have identified as a substance abuser. You should ask your patient for written permission to speak with his or her family members as well as other doctors or program administrators that may need to become involved.

Remember that a large percentage of violence and physical abuse in families is directly attributable to substance use among family members. This means APPROACH WITH CAUTION! Moving too directly or against your patients desires is very dangerous.

Here are just a few things you need to be aware of when dealing with family members of your substance abusing patients:

• the family member may have been harmed physically or psychologically by your patient;
• the patient may change his or her mind about your talking to his family or others and argue that you were never given permission to talk to them and that you are in violation of federal confidentiality laws. Written permission forms are very valuable in these situations;
• discussions with family members that may uncover events that occurred when the person was a child (sexual abuse, physical abuse, neglect) can lead to depression or other severe reactions. It is wise to have a back-up system to which you could refer the person when needed;
• resolving these issues for family members is a long-term process similar to the process the substance abuser must encounter;
• referrals to self-help groups such as Ala-non and Ala-teen provide affected family members contact with other persons dealing with similar issues.
• Half-way homes and centers for battered women are available in most communities and they offer excellent alternatives to remaining in an abusive setting.

You may from time to time encounter patients who are struggling with substance abuse in their family but who are not telling you about this issue. Identification of these people is a difficult task because very few of them will actually come to their physician and ask for help for themselves. There are, however, some symptoms that signal the possibility of trouble at home.

• Children may complain of vascular headaches, abdominal pain, or present with behavioral problems.
• Children who are found to be using drugs themselves are often in families where one or both of the parents are also using and abusing drugs.
• Depression in both children and adults can result from conflicts in the family.
• Patients who ask for medication to "calm their nerves" or to help with sleeping problems are very often dealing with family issues.
• Patients who do not comply with your medication prescriptions may be having difficulty getting financial or other support from home.
• Patients who often cancel appointments may be reflecting the conflicts at home.
• Patients who present with exacerbation of their hypertension, diabetes, or other medical conditions may be responding to the stress they are experiencing at home.

If you suspect a substance abuse problem, it is recommended that you begin by asking your patient what he or she thinks may be causing the problem. If no information is provided, a simple direct question is indicated: "Does anyone in your immediate family use alcohol or drugs or have a problem with these substances." In the case of very young children, the parent should be asked this question.

Even if the answer is no, it is wise to make a note to ask again at your next meeting. This is because of the tremendous influence denial has on family members' ability to deal with these issues. "Denial" is used here not only in the psychoanalytic sense of a single psychological defense mechanism disavowing the significance of events, but more broadly to include a range of psychological maneuvers designed to reduce awareness of the
fact that alcohol or other drug use by a family member is a major cause of the family's problems. Denial becomes an integral part of the family's difficulties and a major obstacle to recovery.

When the patient tells you about a family member that is abusing or possibly addicted to a drug, you may want to consider a referral to a specialized program for further assessment and treatment. If this is not possible, a more in-depth medical and psychiatric assessment should be done. It is important to include an assessment of mental health problems with a focus on depression and suicide risk. Also, once a reasonable rapport has been established with the patient, you may want to take a history of any abuse the patient may have suffered from a substance abusing relative. Finally, testing for sexually transmitted diseases should be offered when appropriate.

Screening these patients for alcohol or other drug abuse is very important since so many affected family members have learned to deal with their problems by using alcohol or other drugs. Also, what is considered "normal" in an alcoholic family may be a very unhealthy standard.

For those patients who do not need a referral or special treatment, brief counseling may be very effective. This counseling should include the following techniques:

• A warm, empathic, non-confrontational approach.
• Basic education about alcohol and drug addiction. You can get pamphlets from local substance abuse agencies or you could simply print out some of the good stuff you can take right off of the WEB, such as this great Definition of Alcoholism and you may want to use a hand-out such as The Alcoholic Family developed by Lutheran Social Services of Wisconsin and Upper Michigan. Explore the WEB for more great stuff that can be useful with your patients.
• Present an invitation to join others who are dealing with similar problems in a support group like Ala-non or Ala-teen. If the patient shows interest, give them some literature on the appropriate program or better yet make a call and hook them up with a "sponsor" who will take them to the first meeting.
• Remind your patient that their self-care and self-esteem are very important and that you are available to help them with these issues.

You should also be aware of a concept called Co-Dependency. The concept of Co-Dependency was developed as a way of explaining how family members of alcoholics, especially their spouses, became emotionally ill apparently as a result of living with a drinking alcoholic or other drug abuser. Alan Brandis, Ph.D. has posted a nice description of this concept on the WEB.

Study Questions

Are the following statements true or false?

1. According to a Gallop Poll, more than 25% of Americans have been affected by a member of their family who is abusing alcohol or other drugs?
2. A primary care physician can always speak to a family member of a substance abuser under the "right-to-know" ethical standard.
3. When talking to a family member of your patient who is a substance abuser, you should confront them with their need to deal with the situation.
4. There is a higher than typical probability that family members of substance abusers have been physically or sexually abused.
5. It is always good and healing for the patient to talk about prior physical or sexual abuse they have suffered with their primary care physician.
6. Unlike the alcoholic, family members can recover from the effects of alcoholism in the family very quickly.
7. Ala-teen is a treatment program for adolescent alcoholics.
8. Ala-non is a support program for those who have chosen to be non-drinkers.
9. A child who presents with headaches and many behavioral problems at school should be screened for family problems that may be affecting his health.
10. Depression always indicates substance abuse problems in the person or in the family.
11. The first thing you should do, if you suspect your patient is suffering from substance abuse problems of a family member, is ask the patient directly "Does anyone in your immediate family use alcohol or drugs, or have a problem with these substances?"
12. If a patient tells you that there are no substance abuse problems in their family, you should let it go and not bring up the subject again until and unless the patient brings it up.
13. Any patient who reports dealing with an alcoholic father should be considered at risk for depression, abuse, and even suicide.
14. If your patient tells you that she has recently been sexually abused by her father, it is appropriate to offer testing for STD.
15. Family members of alcoholics are less likely to have alcohol or other drug problems themselves.
16. According to Alcoholic Family article published on the WEB, the Family Hero is often the oldest or "special" child.
17. Often the second child plays the role of scapegoat in the Alcoholic Family and it is likely that he or she will seek attention through destructive behavior.

1. What is Ala-non and how does it work?
2. What is Ala-teen and how does it work?