JOURNAL ISSUE 16
The Role of Family as/and Social Environment in the Professional Work with Alcohol-addicted Persons
Dr. Marlene Bock, Professor
University of Applied Sciences
First of all I have to beg you pardon because my English is not very good. I am rather good at understanding, but not so good at talking in a professional and differentiated way about subjects. But, I am sure someone will help me if I am looking for the correct words.
I am happy to be here again. Ten years ago was my first time at IUC and now it is my seventh time being here. In previous years I have always taken part in the course Social Work with Children and Youth. Now it will be my first time with the course Developing Neighborhood and Community Support, because my colleague and course director, Ronald Lutz, cannot be here this year. I will try to substitute for him, because Ronald and Dada invited me as a guest director.
I am pleased to be in Dubrovnik with two nice colleagues from our department, Monika Frank and Tilo Fiegler, and with one of our students, Anne Wittig; they will also do presentations today, but on other subjects, so that you will get much information about social work in Germany.
The subject I will talk about today is alcoholism; what it means for the families and how social work should involve the family members in professional work.
Drug abuse, especially alcoholism, is a big problem for the alcohol-addicted clients, and for their families, their social environments and, not the least, society. In Germany we have to work with the fact that 5% of all Germans fulfill the criteria for alcoholism as a disease, as categorized in the ICD 10 and DSM IV, and not only as substance abuse. This means that they need professional help.
Alcohol addiction has a physical and a psychological side, and it also has many psychosocial consequences because it interferes with the roles of all family members.
Another problem is that we often find co morbidity, for example: strange psychiatric diseases and aggressive behavior in special situations and, often, against family members. Another big problem is that some family members, often the wives but sometimes the eldest child of the alcohol-addicted person, act as a co alcoholic. That means that this person has the role of the healthy part of the family and he/she tries to hide the alcohol problem as a family secret.
After a while, he/she is also addicted because he/she depends psychologically on this special role. The co alcoholic contributes unconsciously to the illness of the index client. That is one of the reasons that social work has to intervene in alcohol-affected families.
Other reasons to work with the whole family are that excessive drinkers have disorders in their human relationships, they have disorders in their physical and mental health and they have disorders in their social and economic affairs. These three groups of typical disorders also stress the family members.
Let us look at the children. Children with an alcohol-addicted parent suffer in many ways and need professional help to minimize their risk of also developing psychological or social disorders.
In Germany we have two million children with drug-addicted parents. These children have a high risk of developing symptoms like depression, eating disorders, hyperactivity, antisocial behavior, learning and school problems and of becoming victims of violence and sexual abuse. They also have a high risk of developing a special interfamilial role, such as hero, lost child or scapegoat. Such family roles are not good for the psychological development of the child. But, the highest risk is that many children develop a drug addiction themselves; it is six times higher than the risk to children without alcohol problems in their families.
But, we also have to see that some children who live with an alcohol-addicted parent have or develop protective factors; we call them the resilient children. What factors characterize them? They have an attitude that brings positive reactions from their social environments, they are able to have good communication with persons outside of their families and they have positive self-esteem and believe in their own capabilities to help themselves. These children also have resources in their environments, are intelligent and show good mental health. From these resilient children we can learn which factors the professionals have to encourage while trying to protect other, more vulnerable children from horrible psychosocial consequences.
Perhaps you know the German book by Frank McCourt, The Ashes of My Mother. It is a family story with a father who is a so-called problem drinker, a mother who is helpless and a social environment characterized by poverty. In this story we see that every child in this family has his/her own reactions to and his/her own coping with the multiple family problems and that not any child has a bad future. Some of them become ill and die early; some others show severe social disorders, but two of them become very powerful little persons. They go their own way and take responsibility for the less fortunate members of their family and also for their mother.
In practical social work with families with multiples problems, we also see such differences in the reactions of children from a single family. So it is urgent that we look separately at every child, his/her own risks and his/her own protective factors, in a single family. Often we find one family member who is helpful in coping with the main problem, the alcoholism, and who is able to take the role of a co therapist. But, we have to be careful to not overburden this person and to see also his/her needs. To have personal resources does not guarantee to have no risks.
I will talk more about children and youth later on.
When we look to the psycho-social theories about the causes of drug addiction (Schwarzer, 2004) we see that three factors determine drug addiction: the individual, the drug (here, alcohol) and the environment.
In most of the societies we all come from, every adult is able to buy and consume alcohol. It is part of our lives, as long as we are able to control our behavior. But, if people drink without control, if alcohol abuse turns to alcoholism, we say that people are ill and, therefore, they have the right to get help from professionals. In Germany alcoholism has been accepted as a disease since 1968.
Now let us look at the individual. The individual abuser who uses a drug excessively often wants to flee from real problems into an unreal world. In Germany we say, “Sucht ist Flucht” (addiction is flight). But this flight does not solve problems; on the contrary, addiction makes problems become bigger and bigger. The alcoholic is in a devil’s circle, as we call it, or in a vicious circle, as you call it, I think.
Now let us look at the environment, which includes the family, because family is part of it. The longer a person is addicted to alcohol, the more we see separations of the family or separations of single family members from that person.
At the end of a career of alcoholism we often find people with multiple diseases, irreversible disadvantages and without jobs, domiciles, friends or family members who are still in contact with them. At this point there are only doctors, nurses and social workers, only professional helpers, around them. But in most cases it is a long way up to this point, the drop-out or point-of-no-return, in family and social structures. Mostly it takes years. Nevertheless, we have to intervene as soon as possible if we want to prevent an intergenerational transfer of the problems.
To know which families need help, we need a social environment that supports such families in finding professional help instead of stigmatizing and isolating them. This is because families with alcohol problems often make a secret of it.
We need kindergarten workers and we need teachers, neighbors, bosses and colleagues that don’t look away; that talk to these families; that give them information and show them that they don’t need to be ashamed of the fact that one of their family members is alcohol-addicted.
How can we reach such aims and which methods do we have to use?
When we look at the methods of social work needed in the field of alcoholism rehabilitation, I think, we have to use all three of Germany’s so-called classic methods.
The first method involves working with single cases. That includes the case work with the individual and, also, working with his/her family. The second method is working with groups. This means, in the case of alcoholism, to not only work with groups of index clients in therapeutic contexts, but also to work with groups of relatives/partners/families. In the third method we have to do community work, especially with the aim of prevention.
This means that we want to reach at-risk families at the earliest time and, therefore, we need networking in the communities, public relations and education. That’s primary prevention.
We also need secondary prevention. Here are the target groups, the people who are at-risk: children and youth living in a quarter with alcohol and drug problems. Social workers can reach them in youth clubs and try to show them how to develop self-esteem, how to enjoy spare time and how to cope with problems without using drugs. Therefore, they can use the methods of teaching through experiences and adventure-based learning.
Tertiary prevention includes working with groups for alcohol-addicted persons in the community to try and help them survive. This requires several institutions, for example: homeless asylums, because nearly 95 % of homeless people in Germany are alcoholics; or institutions were they can get food, clothes, showers and basic medical help too. We call them warming rooms or soup kitchens. Also, we need special offers for special client groups in our communities, like street work for youth or housing for children in family crisis and so on. To show how important it is to reach the family as part of the environment of an alcohol-addicted person as early as possible, I will talk more about the social consequences of alcoholism. First, there are problems with partnerships. These are twice as likely as in the so-called normal population.
Second, very often we find problems on the job; alcoholics have problems with job performance and reliability and, therefore, they usually lose their jobs.
A third problem is driving while drunk and having terrible accidents. Another problem we see is that alcohol-addicted clients often show severe delinquencies like excessive physical violence and rape. This rate is nearly 30% higher in individuals under the influence of alcohol. Later on we will see what this means to their children.
These psychosocial problems often arise earlier than physical and health problems and they depend on the personality of the alcohol-addicted person and on the phase of alcoholism he/she is in.
Let us look now at the phases of alcoholism. We find three phases. First, and this is hard to differentiate from abuse, we talk about the critical phase; that means that the person drinks more and more without control. First the individual starts experiencing blackouts and then he/she shows the loss of other interests. Than we see the chronic phase; that means the person starts to drink in the early morning, he/she shows tremors, the loss of alcohol tolerance and is preoccupied with drinking. Then we can have, if professionals intervene and family members no longer act as co alcoholics, the rehabilitation phase. This means that the client has an honest desire for help, a beginning of hope and realistic thinking about his/her own situation, a growing emotional control and has taken the first steps to social and economical stability.
When we look at the professional interventions and possibilities of help, we talk in Germany about the chain of treatment (Behandlungskette). The most important principles therefore are: early intervention, orientation of resources, self-help before professional help, ambulatory help before stationary help, the principle of helping in the community, cooperation between the helping systems and the principle of harm reduction.
The chain of treatment starts with the so-called contact phase. This is the first contact of the alcohol-addicted person with the helping system. The aim in this phase is to build up a stable motivation for therapy. Therefore, we need a change in mental state and the confidence in a significant person, who often has to be a professional.
In the second phase the alcohol-addicted person has to undergo the detoxification of alcohol him- or herself. This phase needs time, from days to weeks, and is mostly subsidized with pharmaceuticals in a clinic. This is a phase with hard physical and psychological pain for the client. The aim is to get the drugs out of the body.
This is the precondition and the base for the next phase, called treatment of habit breaking or therapy phase. Mostly it takes place in special clinics and it needs from three months to one year. The aims of this phase are: recognizing and working on the individual causes of the alcoholism, learning to cope with problems in everyday life and to rehabilitate the person into his/her family, social environment and working life. In Germany nearly 13,000 people per year undergo such treatment.
The fourth phase is the phase of follow-up treatment. The aim is to stabilize the success; here we mostly have out-patient treatment. This includes self-help groups, family counseling in an advertised center, case work and individual psychotherapy.
It is typical for alcohol-addicted persons to have relapses. The greatest risk is in the first 90 days after the end of the therapy phase, phase three. We talk about reintegration shock.
How often one person has a relapse depends on his/her age, gender and family resources.
Only 35 to 40 % stay abstinent after they have passed through the whole chain of treatment.
Now I want to talk again about children, youth and addiction.
We can look on this subject with three different perspectives: the child as an embryo in the body of an alcohol-addicted mother, children and youth as family members to an alcoholic parent, and children and youth as alcohol consumers and abusers.
The greatest impairment is for the baby during the pregnancy. In Germany we have to see 2,200 children per year with an alcohol embryopathy, a mental disability, a small head and body, a typical alteration in the face of the child and various other developmental disorders and retardations. Often the babies suffer from withdrawal symptoms after birth.
At the least two million children live with an alcohol-addicted parent and, as the most vulnerable family members, these kids have the highest risk of developing their own psychopathologies. I will soon talk about this.
But, we also have to look at children as consumers of alcohol. We have no valid data, but we see an increase in the abuse of both legal and illegal drugs. Often we see the combination of cannabis and alcohol abuse. The earlier a child starts, the faster the addiction. The first psychosocial symptoms that can be seen by the social environment are the following:
- social self-isolation
- alcohol- and drug-addicted peers
- no motivation for school and other interests
- more aggressive behavior and a lack of impulse control
- often we see sexual wildness
When we look at the causes and motivations for the abuse of children and youth, we often can see the following points:
- they learned early in their families to consume alcohol when they have problems
- they want to belong to their peer group and want to be cool
- they have excessive demands in many situations
- they have no good coping structure or solution strategies for conflicts
- they try to obtain relaxation from alcohol and they drink to forget their problems (fear, depression, family and school problems etc.)
All these signals can be seen from an observant social environment. This includes family members, teachers, neighbors, medical professionals, social workers and so on. To gain influence it is necessary that the child has confidence in the adult who wants to help him/her. It is also necessary that the helpful adult does not work against the family to which the child belongs.
Also, it is necessary that he/she accepts that alcohol-addicted family members often make a secret of their problems and that they often don’t tell the truth, because these children and youth want to protect their family against intervention by state authorities like the Social Services Department and Youth Welfare Agency.
Social workers try to help the whole family and try to include the social environment. But when family situations are too destructive for the further development of children, we have the obligation to care; we have to separate the children from their families and to look for foster families or other forms of placement.
I think that we also have to work in a political way and to push information into our societies, then the execution of the laws that we have to protect children from drugs will be better. In our country we have laws to protect children and youth from alcohol. But, it is not a big problem for them to buy alcohol in supermarkets and to get it in taverns or discothèques.
These laws are not controlled well enough because we have no increased awareness in our society of how awful alcoholism is for the development of young people. Therefore, as a profession we have to do public relations work and education, not just working with single cases.
Now I will tell you something about the Care-Angry-Guilty-Eye-opener test (CAGE test) because it is a good instrument for a first diagnosis done by social workers; but here I want to say that the differential diagnosis belongs to the medical professionals and other specialists.
The four main questions of CAGE are:
- Did you try, without success, to reduce your alcohol consumption?
- Do you get angry about the criticism of your social environment because of your alcohol consumption?
- Do you have a sense of guilt because you drink?
- Do you need alcohol in the early morning to be efficient?
When someone answers all four questions with “yes”, it is time to try to motivate him or her to work against alcoholism.
It is also time to watch the other family members, to see what kind of help they need, and to look for resources we can find in the family and social environment to combat the alcohol problem instead of ignoring it.
At last I want to look at the method we call “relatives work”; I translate it into “work with relatives”. When we work professionally with the relatives as the most important part of the social environment of an alcohol-addicted client, we try to reach two different aims and therefore we have to think on the following professional and structure conditions.
- In a multi professional team it is the social worker’s task to look for the familial and social resources someone has. We all know that relatives can be part of the problem – we can think of the co alcoholic partners - but they also often are part of the resources our clients have. This means that we need them to talk with us about history and the current situation in the family, to inform us about strain and suffering in their daily lives. We need their point of view on the medical history of the alcohol-addicted client. But it only works by mutual agreement; we are not able to do it without the agreement of our client.
On the other hand, we as the professional helpers have to inform the relatives about the illness (alcoholism), and the possibilities of different medical and social institutions that can provide help. Also, we should not reinforce their feelings of guilt, even when they are part of the problem, because we have to cooperate with the healthy parts of their psychological structure because we want to involve them as partners, not as enemies.
- Social workers who work with relatives have to also have the aim of minimizing their psychological and social strain, to understand them and to help them to find professional help or self-help groups or organizations where they can find protection. Social workers also have to try to prevent the relatives from developing their own disorders or mental health problems.
When social workers try to initiate a trialogue, a talk between three parts, or a dialogue on an equal footing between the clients, the professionals and the relatives, then we have the best chances to help in crises and to ensure that clients and their relatives learn to help themselves.
That is the way professionals can try to contribute to not having a so-called social transmission of the alcohol problem on other family members, especially not on the children in alcohol-addicted families.
Germany is State-of-the-art in the social work profession and it has ordinances that require social workers to work with relatives of clients with psychological illnesses. In working with alcohol-addicted people, we don’t have such standards of quality assurance analysis.
Therefore, I think we need a change in how we look at alcoholism. At the end of an alcohol career we often find single, lonesome people without families, without social networks, often homeless, with multiple suffering, with irreversible impairments and we, as a profession, only have to get care that they can survive.
But if we would, and if we could intervene earlier, it would be more probable that we could activate the resources of family members and other helpful people in the social environment of an alcohol-addicted person. Then we could help our clients to get a chance to overcome their alcohol dependency more effectively.
Questions for the small groups:
- Do you involve relatives in your work with alcoholics? If so, how?
- What standards do you have in your countries for professional work with families and social environments?
- Which problems or conflicts do you see for social workers when they also work with the relatives of their clients?
- Galuske, Michael: Methoden der Sozialen Arbeit, Weinheim/München 2002
- Kreft, Dieter/ Mielenz, Ingrid (Hrsg): Wörterbuch Soziale Arbeit – Aufgaben, Praxisfelder, Begriffe und Methoden der Sozialarbeit und Sozialpädagogik, Weinheim/München 2005
- Schwarzer, Wolfgang (Hrsg): Lehrbuch der Sozialmedizin für Sozialarbeit, Sozial- und Heilpädagogik, Dortmund 2004
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