|Responding to Drug and Alcohol Problems in the Community (WHO, 1991, 109 p.)|
|1. Assessment of drug and alcohol abuse in the individual and the family|
The family can be gravely damaged, or even destroyed, by excessive use of, or dependence on, psychoactive substances by any one of its members. The damage can result from the immediate effects of substance abuse, such as violence resulting from intoxication, or the long-term effects, such as family discord and breakdown resulting from chronic dependence. If any one member of the family becomes dependent on a psychoactive substance, the whole family will be affected in one way or another. In many cases, the family will have undergone a considerable amount of stress long before the problem becomes obvious to outsiders. Also, it is often a member of the family a parent or spouse who makes the initial contact with the PHC worker. Usually during the first assessment interview, the family is in a crisis that requires immediate intervention, and the PHC worker should be aware of this fact.
To a large extent, the general principles of assessment of the family are not very different from those of assessment of the patient. In certain circumstances, the initial assessment will have taken place in the presence of the family member or a relative. More frequently, the family member or the spouse can be interviewed immediately after the patient. In either case, the first interview with the family should be as therapeutic as possible.
The PHC worker should encourage the family members to tell their own story, and should guide them in recounting specific incidents that have led to the referral. Family members should be encouraged to describe and discuss the impact of drug abuse on the victim and on themselves. At the same time, the PHC worker should attempt to assess the degree of stability or instability in the family, and to build up a picture of the family's ability to cope.
The PHC worker should try to find out whether other members of the family use psychoactive substances. Just as the patient can become uncooperative, and deny the existence of a problem, a similar situation may be encountered during a family assessment, and a "conspiracy of silence" can exist. The PHC worker has to be tactful in dealing with this situation.
Alcohol problems in the family, especially among parents, may go undetected for years, while individual members of the family continue to experience stress. Although some families may present directly and voluntarily with the problem, in many cases the PHC worker will have to look for indirect indicators of drug or alcohol abuse in the family, often referred to as "secondary signs and symptoms" of alcohol problems.
These indicators include:
· repeated violence to the spouse or children;
· marital discord or separation;
· financial problems;
· child neglect;
· academic deterioration of children at school;
· delinquent behaviour in children, including drug abuse and truancy;
· history of drug or alcohol abuse in relatives.
The presence of any of these indicators should prompt the PHC worker to probe more deeply into the family's use of alcohol and drugs, if such information has not been volunteered.