Untitled Document

RESEARCH ARTICLES

 


Relevance of family role in the prevention of alcoholism relapse

 

Janaina Rocha SoaresI; Sheila Nascimento Pereira de FariasII; Marilurde DonatoIII;
Maria Yvone Chaves MauroIV; Elaine Franco dos Santos AraujoV; Liane Gack GhelmanVI

IM.Sc. in Collective Health.Occupational Health Nursing Specialist.Professor in Mental Health.Universidade Estácio de Sá. Rio de Janeiro, Brazil. E-mail: janainarsoares@gmail.com.
IIPh.D. in Nursing. Professor. Universidade Federal do Rio de Janeiro, Anna Nery School of Nursing, Public Health Nursing Department. Rio de Janeiro, Brazil. E-mail: sheilaguadagnini@yahoo.com.br.
IIIPh.D. in Nursing. Professor. Universidade Federal do Rio de Janeiro, Anna Nery School of Nursing, Public Health Nursing Department. Rio de Janeiro,Brazil. E-mail: marilurdedonato@superest.ufrj.br.
IVPh.D. in Nursing. Professor. Universidade Federal do Rio de Janeiro, Anna Nery School of Nursing, Public Health Nursing Department. Rio de Janeiro, Brazil. E-mail: mycmauro@uol.com.br.
VPh.D. in Collective Health. Professor. Universidade Federal do Rio de Janeiro, Anna Nery School of Nursing, Public Health Nursing Department. Rio de Janeiro, Brazil. E-mail: elainefsaraujo@uol.com.br.
VIPh.D. in Nursing. Professor. Universidade Federal do Rio de Janeiro, Anna Nery School of Nursing, Public Health Nursing Department. Rio de Janeiro, Brazil. E-mail: lgghelman@gmail.com


ABSTRACT: The object of this study is family support as a preventive factor for relapse. This study aimed at analyzing family’s relevance in prevention of alcoholism relapse. This is a descriptive, qualitative study with focus group. Subjects were thirty-one (31) clients aged 18 to 65, assisted at the Municipal Health/RJ and the Center for Studies, Research and Reference on Alcoholism and Addiction, from July to September, 2009. During the focus groups, participants spoke about family relevance in the prevention of alcoholism relapse, and highlighted episodes of violence and ensuing results on children’s frame of mind due to alcohol abuse. Results call for the implementation of a monitoring program for the children of alcoholics. Their imbalanced family environment can compromise their emotional frame of mind and undermine their psychic development.

Keywords: Alcoholism; relapse; family; family support.


 

INTRODUCTION

This paper results from the thesis defended by one of the authors and discusses the category family in the prevention of alcoholism relapse.

Alcohol has been present in people’s lives since early times, when drinks were fermented. As from the Industrial Revolution, drinks started being produced industrially, with higher levels of alcohol. Thus, the drink that used to be consumed during meals as a less contaminated source than the water, which was not treated appropriately at that time, became strong and was sold at a low cost, granting access to a larger number of people1.

Alcohol is a legal drug whose consumption is admitted and often encouraged by society but, when this consumption becomes excessive, it turns into a problem that can cause addiction, known as alcoholism2.

In the health context, the Manual of the International Classification of Diseases and Health-Related Problems (ICD-10) defines the Alcohol Dependence Syndrome as a set of behavioral, cognitive and physiological phenomena developed through the consumption of a psychoactive substance, typically associated with the uncontrollable desire to use the drug, with difficulties to keep the consumption under control, with continuing use despite its adverse consequences, with the greater priority attributed to the drug use to the detriment of other activities and obligations, with increased tolerance of the drug and, sometimes, with a state of physical abstinence3.

As a result of the alcoholism disease, the people loose their freedom to decide on whether or not they want to use the alcohol, leaving them at the mercy of their own dependence to determine when to use it. This characterizes alcoholism as a progressive and fatal disease that affects individuals in their physical and mental integrity4.

In that context, the prevention of relapse emerges, which is a behavioral maintenance program for use in the treatment of problems the addiction causes, based on complete abstinence from the substance the individual uses, or on the maintenance of programs to regulate individual behaviors, which consisted in abstinence or moderation with regard to the use of the psychoactive substance5.

It is known that the family can serve as a protection factor in the risk for substance abuse in this phase of relapse prevention, as it is associated with the return to substance use after a period of abstinence due to a lack of family support, among other circumstances6.

And this search for recovery is triggered by critical experiences like situations of helplessness and physical weakness and revitalization of family bonds, which served to recover a position in relation to oneself and the abuse of psychoactive substances6.

Despite the magnitude of the problem, for some authors7, this theme is hardly explored in the literature, mainly with regard to the family support as a protection factor for drug dependence.

Based on these references, the need was perceived to outline the importance of the family in the prevention process of alcoholism relapse as the research problem. Thus, the following objective was defined: to analyze the importance of the family in the prevention of alcoholism relapse.

LITERATURE REVIEW

Human beings can react to a stressful or challenging situation in different ways. In the case of alcoholics, one of these reactions can be the flight from reality, characterized by alcohol abuse. Over time, this kind of behavior can turn into an increasingly compulsive habit, entailing negative consequences for health8.

Alcoholism is a silent disease in which patients and their relatives do not acknowledge it as such, denying its presence and the disorders it entails. Over time, the consequences of this dependence start to provoke changes in the family environment, and both the family and the alcoholics end up suffering.

Alcoholics are binge drinkers, whose dependence entails mental disorders, besides manifestations that affect their physical health and individual reactions and, therefore, need treatment9. Once installed, the disease called alcoholismhas no cure, with abstention as the only solution, reminding that, when alcoholics quit drinking, they are not considered cured, but recovering10.

Alcohol works as an escape mechanism for feelings linked with personality traits, in which fantasy represents a source of satisfaction. Among the main environmental factors that influence the emergence of alcoholism, peer pressure and induction from the family context to drink stand out11.

Approximately one out of every three alcohol addicts have a family history of alcoholism, and the probability of separation and divorce among couples increases thrice when this involves an addict12.

Relapse is the moment when an addict who is recovering returns to using the substance that causes dependence, as an event unconsciously programmed by the dependent, which is concretized at the exact time (s)he returns to using the substance13. It can be considered a transition process; in this phase, a series of events may or may not be followed by a return to the baseline levels of the previous behavior, as part of a change process that is essential for the person to learn from his/her experience and restart their abstinence14.

According to the relapse prevention model, its determinants are classified in two categories: immediate, which result from the confrontation between a person who actively engages in achieving and maintaining the abstinence and a current risk scenario; and antecedents, involving forces that act unconsciously, enhancing the vulnerability and probability of a relapse15.

Alcoholics can be socially considered as ill or as individuals with personality disorders. It is important to highlight that, after the abstinence phase, the reconstruction of the alcoholics’ identity depends on significant people’s ability to believe in them, thus encouraging them to avoid the relapse.

METHODOLOGY

Descriptive study with a qualitative approach, which permitted analyzing the role the family plays in the prevention process of alcoholism relapse. It was undertaken at the Rio de Janeiro Municipal Secretary of Health and Civil Defense (SMSDC-RJ), which develops the Project Arco-Írisand at the Teaching, Research and Referral Center for Alcoholism and Addiction (CEPRAL/Teaching Hospital São Francisco de Assis/Universidade Federal do Rio de Janeiro), between July and September 2009.

The study subjects were 31 clients, including 11 municipal public servants who sought or were forwarded for specialized care due to problems related to alcohol abuse, and 20 subjects who were members of the Reflection Group, an activity that is part of CEPRAL. The selection criterion used was intentional, considering the participants’ homogeneity, with a view to obtaining in-depth results on the theme, considering that each group has its specific place in the social reality.

The following criteria were considered for inclusion in the sample: alcoholics (men and women), between 18 and 65 years of age, professionally active or not, with higher, secondary or primary education level, who voluntarily agreed to participate in the study. The clients signed the Free and Informed Consent Form (FICF). The letter P was used to identify the participants, followed by a number, according to their order of inclusion in the study. For example: P1, P2...

Focus groups were chosen as the data collection technique. For this purpose, the author counted on the participation of two moderators for each practice context. The sessions were recorded in MP3 (recorder), with the participants’ authorization.

After the collection, the data were categorized, coded, registered and analyzed. Based on the content analysis, the category The family was elaborated, with two themes and 28 (46%) registry units (RU).
The study was submitted to the regulatory procedures of the Rio de Janeiro Municipal Secretary of Health and Civil Defense Research Ethics Committee (CEP) and approved on March 2nd 2009 - CAAE: 0019.0.314.000 – 09,under protocol 25/09. For the focus groups held in CEPRAL activities, approval for the research was obtained from the DEP of Anna Nery School of Nursing, under protocol031/2007, as part of the community service project entitled The problems related to the use, abuse and dependence on alcohol and other drugs in community health.

RESULTS AND DISCUSSION

In the focus groups, the participants discussed about the importance of the family to prevent alcoholism relapse, highlighting the episodes of violence and the example given to the children due to the alcohol abuse.

Domestic violence

The family can be described as a system in which each member is interconnected, so that any change in one of the parts affects the entire structure and each member is a participant in this phenomenon16. One of these changes is domestic violence in families with a history of alcoholism17, and its incidence has been considered higher among drugs abusers in most societies and cultures and present in different socioeconomic groups18.

Domestic violence is considered as any action or omission that negatively affects the wellbeing, physical or psychological integrity or freedom and the right to the full development of a family member, which can be committed inside and outside the home by any of its members in a relationship of power with the attacked person18.This violence results from problems that affect the intra-family groups, like alcohol and drugs abuse for example.

By the way, when asked about the motive that made them look for the relapse prevention, 15 participants alleged domestic violence, as certain testimonies proved:

[...]so as not to destroy my family, because I reached the point of aggression. (P1)

[...]the main motive was not to destroy my family, because I used to hit my wife and children. (P3)

[...]it was not to bring my family to an end, which I attacked so much, physically and psychologically. (P14)

[...]I am afraid that my family will end, that my wife and children will leave, because I used to hit them. (P21)     

Hence, it was verified that the option to stop drinking resulted from the acknowledgement that, when they were under the effect of the alcohol, the episodes of domestic aggression were constant. Therefore, and considering that alcohol is the drug that most causes behavioral disorders, the health professionals should pay attention to the detection of possible aggressors and, if they verify this kind of event, they should forward both the victim and the aggressor to the competent entities for help in the recovery process.

In this decade, the media in general have strongly alerted to domestic violence related to alcohol abuse, reporting cases like physical aggression that can lead to the victim’s death, mainly in relation to children or elderly people.

Alcoholism involves situations that can cause violence in the family context. Therefore, when aware, the alcoholic perpetrators perceive that they can be abandoned by the attacked family, as they confirmed in their testimonies:

I am afraid to return to the alcohol, due to the family abandonment. (P18)

[...]I do not want my family to abandon me, that’s why I quit using alcohol. (P30)           

The individual perceives that, at first, they continue being surround by their family and friends; when the disease is established and progresses, however, the people who surrounded them start to take distance. In some situations, the family gets isolated from the patient out of fear of the moments of violence the alcohol causes.

That is when the perception of isolation emerges, of being in the company of the alcohol only, which entails an anguishing void and the certainty that something is wrong and needs to be changed. Feeling alone and weakened, the alcoholics seek help and a way to go back to their earlier life, as the participant reported:

When you are at the bottom of the pit, it’s very difficult for a loved one to reach out in order to get back to social life. (P23)                           

When the family tends to marginalize the alcoholic, it is important for the health professional to alert to the need for support in order to avoid future relapses as, without this support, the return to social life will be even more difficult. In the authors’ professional experience, it has been observed that, for alcoholics without family support, it is very difficult to stop drinking or avoiding relapse. Therefore, the family members need to understand that the relapse is a phase of alcoholism and that, if it happens, the motive may lie in the family context.

Hence, the problems increase with the progression of the disease, obliging the family to go through a kind of restructuring, due to the changes provoked by a member who no longer acts collectively, but in function of him-/herself.

In summary, the alcoholic’s family is directly affected by the evils of alcoholism, mainly when the sick person is the family provider. By no loner being able to perform that role and to attend to the family expectations, financial as well as moral losses emerge, which result in the loss of group leadership.

Alcohol is indicated as the substance that is most related to the behavioral changes that result in violence, especially domestic violence19, as the following reports confirm:

[...]I have drunk for years but, when I was sober, I have always been calm. Now, when I drank, it was horrible, I attacked everyone at home. (P12)

[...]if I hadn’t been completely drunk, I would not have done that [attack the family member] (P17)

[...]I have never been accused of committing violence when I was sober. I used to do that [violence] when I was very drunk. (P28)

In view of the above, demonstrations of prejudice, indifference, denial and fear in view of the domestic violence problem and its consequences should be avoided, acting with a view to the early detection of alcoholism and the prevention of potentially dangerous situations. 

Fear of being a bad example to the children

The parents’ example is an important factor in the initial drug consumption pattern, especially in cases of children with social relationship difficulties, as social models and expectations influence the behavioral patterns learned20. In that sense, the alcoholics manifest true concern with the possibility that their children might follow their example, as follows:

I am afraid that one of my children might follow the same course and start drinking too. (P2)

I am afraid that my son might follow the same course of alcoholism. (P5)

My fear is to see a daughter of mine in such a case [alcoholism]. (P7)

[...]I am afraid that my children will drink too, because I drink, by husband also likes to, and my father was an alcoholic. (P19)

When aware of their illness, the alcoholics demonstrate the desire not to give a bad example to their children who follow their trajectory. In addition, the possibility of seeing a child involved in a similar situation and of not being able to advise them about the evil the course chosen entails is a source of frustration, as it directly affects their function as parents and guides.

I did not want her [daughter] to discover ever, so as not to see me as a bad element, something that’s no good as a father. (P16)

They are my children… I do everything not to become active again, so that they won’t see me drunk again. (P21)

It’s my youngest son because, besides me, his grandfather also used to drink. (P23)

One reason is that it makes me very scared of not giving a good example to my daughters. I keep on imagining: didn’t they ever notice? Don’t they know? If they know, they have never made any comment… but I don’t think so... I am very scared that they will charge me for that. (P26)

Thus, the alcoholics’ concern is confirmed, considering that the family context is seen as an important part in the determination of the alcohol consumption, due to strong signs that this consumption is associated with neglect, rejection, emotional distancing from the parents and family tension, with the aggravating factor that the children’s immaturity can contribute for the children to adopt the parents’ drinking pattern20.

I am afraid that they will do the same. (P30)

I don’t drink at the bar, I drink at home and I am afraid that I will lose control and my children will notice. (P31)

It is known that adolescence is a phase when individuals are starting their search for their own identity, considering themselves immune to everything and even indestructible. Hence, for them, health is a good that will never be lost, because it is inherent to them21. In the adolescents’ case, they believe that they are “protected” against accidents and other problems, including health problems, making them vulnerable to risk situations, like in the case of alcohol abuse22.

It should be reminded that, in general, the health professionals only become aware of the existence of alcoholics’ children when they report on the difficulties their children start to present in school23. Therefore, it is fundamental that, as soon as the alcoholics are received at the treatment institution, the professionals work effectively with the family group, as it has been verified that relapse can only be prevented successfully if the family is present and aware of the problem.

CONCLUSION

Although the evils of alcoholism directly affect the family, it is important in the alcoholic’s recovery process, and the health professionals should explain this to the family members, so that they understand that alcoholism is a disease and that family support is fundamental in the prevention of relapse, and also serves as a learning experience of the best way to deal with the alcohol with a view to building a healthy family relation.

Based on the information collected from the alcoholic subjects, their efforts to prevent relapse were perceived, showing the desire that it does not happen to prevent them from losing credit with their children and other family members.

As a result of this analysis, it can be concluded that it is important to implement a monitoring program for the children of alcoholics as, in their unstable family environment, they can get emotionally shocked and their mental development can be undermined.

Health professionals serve as a link between the family and the alcohol. The professionals should get to know not only the patient’s, but also the family’s needs though, which is still ignored and acts as a mere support in the treatment of alcoholism.

And, to facilitate the process, relapse prevention should be incorporated as a priority in the agenda of public services and nurses, together with the health team, can act as the main articulator in this process.

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