专家视点——治疗酗酒全家有责

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？为什么配偶丛恿对方继续饮酒？从Jasper女士的角度来考虑这些问题，最简单的处理方式是允许酒精依赖的丈夫继续饮酒，而不是激化问题和招致暴力或家庭破裂。如果她丈夫是家庭支柱，那么问题将会更大，Jasper女士会急于寻找借口原谅他，以免他丢掉工作。

此外，酒精依赖者或许在一段时间内有所节制、表现较好，使得家人认为问题得到解决。导致关系不正常的另外一个因素是部分家庭成员对维护自身形象的需求，其结果是家庭成员试图隐藏问题。最后他们可能忽视了自身需求，而致力于营造平和的家庭氛围，希望酒精依赖者感觉到压力较小而变得有所节制。

从本质上讲，家庭成员尽最大努力处理这一问题，他们所做的一切都可理解为应对酒精依赖配偶压力的正常反应。为酒精依赖亲属提供有利于康复的环境，又不至于使家庭成员过度负责的最佳应对行为是什么呢？

确定最佳行为的方法之一是应用行为诱导量表(BES)。BES关注可观察的行为而不是推测动机。BES包括两部分内容：诱导行为量表和诱导观念量表。诱导行为量表包括了诸如给患者酒钱、为患者买酒、代做患者因饮酒而未做的家务等内容。诱导行为可能非常细微，比如为家庭成员或朋友寻找借口。诱导观念量表包括“我不惜一切代价去维持与配偶在一起”或“我应该尽最大可能保护配偶免受饮酒造成的负面结果伤害”等。

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。

诱导行为

该研究显示，诱导行为普遍存在但并非一成不变。例如，来自配偶自身高度认可(回答分类为有时、经常和非常频繁)的具体事项包括：承认向家庭成员或朋友说谎或制造借口(69%)、完成配偶疏忽的家务(69%)、威胁分手但从未实施(67%)、因饮酒改变或取消家庭计划或社交活动(49%)、为配偶制造借口(44%)等。值得注意的是，30%的受访者表示给配偶提供酒钱，或当着配偶面饮酒。所有这些诱导行为在过去1年中都存在，仅有1对配偶否认存在所有20项诱导行为。

诱导观念

该研究还揭示了具体的配偶观念与诱导行为的关系。研究者确定了13项影响配偶诱导行为的想法，例如“我的配偶没有我的帮助不行”和“在困难的时候，我应该承担更多的家庭责任和义务。”

医生该做些什么？

我们如何帮助家庭成员应对来自与酒精依赖者抗争的身心压力？诱导行为或许是绝望的反映，医生应对配偶进行抑郁——至少是情绪低落——的评估，分析具体哪种婚姻行为促进饮酒或影响康复，哪种行为有助于康复。让配偶知道他们做的事情中好的方面，并鼓励他们继续做下去，这永远是非常重要的。

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。

此外，配偶应对技巧训练可改善应对能力，也可参加嗜酒者家庭互助会(Al-Anon)。行为配对治疗在促进戒酒和改善关系方面比个人治疗更为有效。看一下O’Farrell博士的项目，在临床实践开展一些O’Farrell博士的夫妇治疗训练非常容易。

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.

Enabling Behaviors

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.

Enabling Beliefs

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.