2012-05-25 不详 网络
作者：科罗拉多大学丹佛分校精神病学副教授ALISON M. HERU博士Jasper女士在其丈夫入住戒酒病房时向护士诉说道：“我丈夫酗酒，但别人却说我是促成者，是共同依赖者。他们什么意思？当我丈夫喝酒时我该怎么做？把酒瓶子夺过来？那样他会揍我的。如果我不给他酒，他就会开始攻击我。我认为问题在他而不在我，我不应该对他的饮酒承担责任！” 什么是共同依赖者？谁是促成者？为什么配偶丛恿
作者：科罗拉多大学丹佛分校精神病学副教授ALISON M. HERU博士
家庭研究可告诉我们许多有关酒精依赖者家庭成员的诱导行为，Robert J. Rotunda博士及其同事曾进行过这类研究(J. Subst. Abuse Treat. 2004;26:269-76)。Rotunda博士考察了42对夫妇的情况，其中一方符合DSM-Ⅳ酒精依赖诊断标准。男性29例，女性13例。患者平均年龄43.9岁，配偶平均年龄44.3岁。约95%为合法夫妇，平均共同生活13年。研究者向配偶双方提供BES。
根据Timothy J. O’Farrell博士的研究结果，应鼓励夫妇加入婚姻家庭治疗(MFT)，这对于治疗酒精依赖效果极佳(J. Marital Fam. Ther. 2012;38:122-44)。即使酒精依赖者不愿寻求帮助，MFT也可有效帮助家庭成员更好应对和激励酗酒者接受治疗。
BY ALISON M. HERU, M.D.
Elsevier Global Medical News
“My husband is an alcoholic. They tell me I am an enabler! They say I am codependent,” Ms. Jasper stated to the nurse as her husband was being admitted for alcohol detox.
“What do they mean?” she continued. “What am I supposed to do when my husband drinks? Wrestle the bottle from him? Then he would just slug me. If I don’t give him what he wants, he starts, you know, getting aggressive with me. I don’t think I am the problem here. He is the one with the problem. I am not to blame for his drinking!”
What is codependency? Who is an enabler? Why would spouses encourage their partners to keep on drinking? Think of these issues from Ms. Jasper’s point of view. It is easier to allow her alcohol-dependent husband to continue drinking rather than confront the problem and face either violence or a break-up of the family.
If he is the main breadwinner, the stakes are even higher. Ms. Jasper might encourage him to continue going to work – and might be eager to make excuses for him so he won’t lose his job.
Besides, people with alcohol dependence might gain sobriety and do well for periods of time, leading the family to believe that the problem is solved.
Another factor that can lead to this dysfunctional way of relating is a desire on the part of the family to preserve its image. As a result, family members might try to hide the problem. In time, they might forget about their own needs and devote their lives to trying to maintain a calm family atmosphere, hoping that the person with alcohol dependence will feel less stress and become sober.
Essentially, families cope as best they can. Whatever behaviors they demonstrate can be understood as normal reactions to the stress of trying to cope with a spouse who has alcohol dependency.
What are the best coping behaviors that provide a supportive environment for recovery without family members becoming overly responsible for their ill relative?
One way to determine this is to use the Behavioral Enabling Scale (BES), a clinically derived instrument that assesses enabling behaviors. The BES emphasizes observable behaviors rather than inferred motives. The BES has two components: the enabling behaviors scale and the enabling beliefs scale. The enabling behaviors scale includes items such as giving money to the patient to buy alcohol, buying alcohol, and taking over neglected chores because she or he was drinking. Enabling behaviors can be subtle, such as making excuses to family or friends. The enabling beliefs scale includes items such as, ‘‘I need to do whatever it takes to hold my relationship with my partner together’’ and ‘‘I should do my best to protect my partner from the negative consequences of his/her alcohol use.’’
Family research can tell us quite a bit about enabling behaviors in families with alcohol dependence. One such study was conducted by Robert J. Rotunda, Ph.D., and his colleagues (J. Subst. Abuse Treat. 2004;26:269-76).
That study looked at 42 couples in which one partner met DSM-IV criteria for alcohol dependence. In all, 29 patients were men, and 13 were women. The mean age of the patients was 43.9 years, and their partners’ mean age was 44.3 years. Some 95% of the couples were legally married and had been cohabiting for an average of 13 years. Investigators administered the BES to both partners.
The study found that enabling behaviors are prevalent but not consistent. For example, “specific items of strong endorsement [that is, collapsing the response categories of sometimes, often, and very often] arising from the partners themselves included admission ... to lying or making excuses to family or friends (69%), performing the client’s neglected chores (69%), threatening separation but then not following through ... (67%), changing or canceling family plans or social activities because of the drinking (49%), and making excuses for the client’s behavior (44%),” the investigators wrote.
“Notably, 30% of the partners sampled indicated they gave money to the client to buy alcohol, or drank in the client’s presence.”
All of the enabling behaviors had occurred over the past year, and only one partner of the 42 clients who participated in the survey denied engaging in any of the 20 enabling behaviors.
This study shows the extent to which most partners have engaged in some enabling behavior.
Another concept that the study explored was the relationship between specific partner beliefs and enabling behaviors. The investigators identified 13 “partner belief items” that factor into the partner’s enabling behaviors.
Examples of enabling beliefs include ‘‘My partner can’t get along without my help’’ and ‘‘It is my duty to take on more responsibility for home and family obligations than my partner in times of stress.’’
What Should the Clinician Do?
How can we help families cope with the psychological and physical strain that might result from interaction with those struggling with alcohol dependence? Enabling behavior might reflect hopelessness, and partners should be assessed for depression or at least demoralization. Clinicians should assess which particular spousal behaviors reinforce drinking or interfere with recovery, and which behaviors are supportive of recovery. As always, it is important to let partners know what they are doing well, and to encourage them to continue.
The couple can be encouraged to enroll in marital family therapy (MFT), which can have excellent results for treating alcohol dependence, according to Timothy J. O’Farrell, Ph.D. (J. Marital Fam. Ther. 2012;38:122-44). Even if the spouse with alcohol dependence is unwilling to seek help, MFT is effective in helping the family cope better and in motivating alcoholics to enter treatment.
In addition, spouse coping-skills training promotes improved coping by family members, as can involvement with groups such as Al-Anon. Behavioral couples therapy is more effective than individual treatment at increasing abstinence and improving relationship functioning.
Take a look Dr. O’Farrell’s program. It is easy to implement some of his couples therapy exercises into your clinical practice.
This column, “Families in Psychiatry,” regularly appears in Clinical Psychiatry News, an Elsevier publication. Dr. Heru is an associate professor of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.