Transcript Family Interactions

Family Interactions
Margaret Jarvis, MD
Marworth
Geisinger Health System
Family Disease?
 Some concern for pathologizing family’s
response to identified patient’s disease
What is a family?
 Love (agape) :
 The willingness to act in a caring way even
when you don’t feel like it
 Recognition of self, other and the
coupleship as distinct entities and
willingness to be loving to all
What is a family?
 Needs of the relationship (coupleship)
need to come first
 Needs of the children need to come first
Family disease?
 In addiction, the needs of the addiction
always comes first
Family disease?
 Addiction is disease of chaos and
dysfunction
 Family members attempt to re-establish
function
 Love and caring
 Sense of normalcy/homeostasis
Family disease?
 Over time, behaviors of family members
altered or driven in reaction to the
addiction
 Family members behaviors toward the
addicted member are addictive in
themselves
 Preoccupation to the neglect of other
concerns
 Shame
Change in human systems
 Generally, humans only change in response to
pain
 Change will occur when the pain is great
enough
 Enabling systems prevent the identified patient
from experiencing pain
 Family members may prevent pain in one
another if it threatens the stability of the system
Change in humans
 The family (and the individuals) will be
healthier for every pain it feels and grows
through
How to address the family
 System to achieve abstinence
 Treatment or external control
 Very initial stabilization
 System to maintain abstinence
 Education about effect of disease on
member’s behaviors
 Contract between addicted person and
family about expectations
How to address the family
 Contract may include graduated steps of
treatment/intervention as responses to
relapses
 Contract to include agreement that family
members get some attention
(professional or 12 –step)
How to address the family
 Even in face of relapses, work with the
family (without the addicted person) can
continue
 Extended support needed – keep energy
off of addicted person (and therapist!)
How to address the family
 Assessment of identified patient as usual
 Assessment of family includes
 other member’s use histories
 Family’s responses to intoxicated and sober
behaviors
Family Roles
 Classic system of naming typical
responses to disease
 All the roles:
 Are rigidly held and are reinforced by other
family members
 Enable denial of alcoholism
 Allow family to function as a unit, allows
some individual function but NOT FULL
HEALTH
Family Roles
 Caretaker: usually adult, sometimes child
– loses self in caring for others
 Hero – usually child who excels
 Reinforcement for achievement leads to
narcissism
 Scapegoat – usually child identified as a
problem
 Carries the shame for the family
Family Roles
 Mascot – creates diversion away from
alcoholism. Usually a child.
 Lost child – usually a child, is low
maintenance
How does the FOO predict
kids’ use?
 Suburban, higher SES:
 Parents more tolerant of drug use than of
other non-acceptable behaviors
 Parents REALLY knowing what kids were
doing/where/with whom decreased use
 “Containment” – predictable consequences
for behavior reduced use
Luthar et al., 2008
How does the FOO predict
kids’ use?
 Low SES:
 Boys who have higher use later (20’s-30’s)
 Higher alcohol use age 16
 Lower achievement scores age 12
 Maternal use age 16
 Externalizing behaviors age 9
England, et al., 2008
How does the FOO predict
kids’ use?
 Low SES
 Girls who use more later (20’s to 30’s):
 Drinking more age 16
 Higher achievement age 12
England, et al., 2008
How does the FOO predict
kids’ use?
 Urban African American
 Both boys and girls: in families with more
rules about drug/alcohol use, less likely to
initiate tobacco or alcohol
Doherty, et al., 2007
How does the FOO predict
kids’ use?
 Urban African American
 Boys and marijuana:
 More likely to use than girls (1.5x)
 Female-headed household and rule-setting affect
use
 Girls and marijuana:
 Family cohesion reduces risk
Doherty, et al., 2007
How does the FOO predict
kids’ use?
 Urban African American
 Both genders:
 Physical and frequent discipline early increases
heroin and cocaine
 Maternal substance use increases heroin and
cocaine
 Girls:
 More rules about drug use reduces risk of heroin
and cocaine
Doherty, et at., 2007
How do genetics
contribute?
 Unequivocal human and animal data to
say there is a big genetic contribution
(50-60% of variance)
 Multi-gene
What genes might
contribute?
 Glutamate receptor genes (alcohol)
 Cannabanoid receptor gene (nicotine)
 Taq1 (alcohol, all addictions) – D2
receptor deficiency
 ALD AST (alcohol)
 NO ONE GENE DOES IT ALL
How do genetics
contribute?
 For initiation and early patterns of use of
alcohol, cannabis, nicotine:
 Family and environmental effects more
important in early life
 Genetic effects more influential later
Kendler, et al. Arch Gen Psych,
2008
References
 E.E. Doherty, K. M. Green, H.S Reisinger, M.E.
Ensminger. Long-term patterns of drug use among an
urban African-American cohort: the role of gender and
family Journal of Urban Health: Bulletin of the New
York Academy of Medicine 85:2, 2007
 M.M. Englund, B. Egeland, E. M. Olivia, W. A. Collins.
Childhood and adolescent predictors of heavy drinking
and alcohol use disorders in early adulthood: a
longitudinal developmental analysis. Addiction
103:supp. 1, 2008
 S.S. Luthar, A.S. Goldstein. Substance use and
related behaviors among suburban late adolescents:
The importance of perceived parent containment
Development and Psychopathology 20, 2008
References
 Kendler, K.S., E. Schmitt, S.H. Aggren,
C. A. Prescott. Genetic and
environmental influences on alcohol,
caffeine and nicotine use from early
adolescence to middle adulthood.
Archives of General Psychiatry, 65:674682.