Family's role in the development and therapy of alcohol dependence
POMINI V.
Psychiatrist, Program "ATHINA", 1st Psychiatric Clinic, University of Athens - OKANA

Alcohol dependence is a complex phenomenon which depends on the interaction between genetic and psychological individual characteristics and family, social and cultural aspects.

The interest towards families of alcohol dependent individuals developed, since at least four decades, according to three different approaches: 1. the family as a "victim" of dependence, with focus on the harmful consequences of dependence on alcoholic's relatives, especially spouses and children; 2. the family as a dysfunctional system which contributes, in differerent ways, to the maintenance of the problem; 3. the family as a main source of help and support for the alcoholic and the major role which it can play in both prevention and treatment.

Therapeutic interventions addressed to alcoholics and their family has to consider all these three levels to be effective.

The paper reviews the main theories regarding the dynamics and the organisation of family systems with a problem of alcohol dependence, the negative influence that this problem may have on alcoholic's children and partners, the main models of family-focused interventions, and their effectiveness in the treatment of alcohol abuse and dependence.

According to Steinglass' theory of "alcoholic family" each family of alcohol dependent individuals faces a situation which is chronic, cyclic, presents repeated phases of "wet" and "dry" behaviors related to the use of the substance, and has a development into time with serious physical and psychological problems not only in the dependent individual but also in other family members. The "alcoholic family" is a system in which alcoholism and alcohol-related behaviours have become the central issue around which family life has been structured, altering the family members' roles and the family balance between stability and growth.

Alcohol abuse and dependence plays a central role in couple interaction: Bepko's theories of "responsibility trap", the idea of "control game" and literature about the role of alcohol in violent couple interaction are reviewed, as well as the concept of "co-dependency" and the main critiques to it.

Alcohol dependent individuals often refuse or abandon treatment. There is evidence of effectiveness from research evaluation of programs addressed to family members, in order to promote the entry and engagement of alcoholics into treatment. Approaches like the "Pressure to Change", the CRAFT (Community reinforcement and Family Training) and the ARISE (Relational Intervention Sequence for Engagement) have shown a solid evidence of effectiveness in treatment engagement and retention for alcohol and substance abusers. Interventions which are offered to family members have significant effects also in terms of reducing their own stress symptoms and changing their coping strategies, which in turn influence the alcoholic's behavior.

Family-based treatment interventions for alcohol abuse have been evaluated as helpful and cost-effective. The joint involvement of family members in the treatment is provided by different therapeutic approaches: systemic family therapy, marital therapy, behavioural-cognitive couple therapy, community reinforcement programs, multi-family therapy. These approaches are different in structure and techniques but they are all inspired by a common concern towards the relational and social context and their main role in promoting health. Encephalos 2009, 46(2):84-91.

Key words: Alcohol, dependence, family, family therapy, couple therapy.