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Protocols
CHEMICAL DEPENDENCY:
A PROTOCOL FOR INVOLVING THE FAMILY

Alcoholism and other forms of chemical dependency are common problems that
continue to frustrate physicians and health care professionals. Despite theprevalance
of these issues in practice, few primary care physicians would claim expertise in the
diagnosis and initial management of drug and alcohol problems. To emphasize the
importance of this topic to all physicians, an entire issue of the Journal of the
American Medical Association was recently devoted to alcoholism and drug abuse.
(4). The purpose of this protocol is to encourage physicians to utilize the patient's
social network, usually the family, in the diagnosis and initial management of
suspected chemical dependency or chemical abuse. A preliminary discussion of this
protocol has been published in a volume entitled Family Therapy and Family Medicine (1). More recently, Stephens has suggested a somewhat similar approach (6).
PROTOCOL
Step 1. Be Open to the Diagnosis
Physicians and other health care professionals should be open to the diagnosis
of chemical dependency/abuse in many patient encounters, even when there are no
biological or laboratory clues. Trauma, uncontrollable hypertension, depression,
anxiety, gastric distress, insomnia, and sexual dysfunction are some common presenting complaints that have been associated with alcoholism and chemical dependency/abuse.
When faced with these types of patient problems, it is important to review family
and other close relationships in the assessment of the presenting complaint. Only
by assessing the social context of the medical problem is it possible to make an early
diagnosis of chemical dependency/abuse. When medical problems are unusually
recurrent or unexpectedly chronic and coexist with serious family conflicts, an
underlying diagnosis to be considered is chemical dependency/abuse. The prevalence
of this disease is sufficiently high that based on clincial evidence, physicians should
be making the diagnosis frequently.
Readers are invited to submit protocols that they have found useful in their work with families in
health care settings. Correspondence should be addressed to William Doherty, Ph.D., and Macaran A.
Baird, M.D., Department of Family Medicine, University of Oklahoma, 800 N.E. 15th Street, Oklahoma
City, OK 73190.
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Step 2. Take a Family History

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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Physicians usually see patients alone. If the physician wants to eventually involve
the patient's family in the management of a medical problem, it is useful to introduce
the idea of the importance of the family by taking some type of family history. The
genogram is a quick and convenient method of obtaining this information and is
a graphic demonstration of the physician's interest in the patient's family.
Step 3. Assemble the Family
If the identified patient is in the hospital, it is relatively easy to obtain a family
interview. For most families, hospitalization of one family member is a crisis. Physician authority is high at this moment. Family vulnerability is at its peak. These
factors create a favorable climate for involving the patient's family in the diagnosis
and management of any disease. For many families, a physician's request for an
interview or "discussion" of the patient's medical problems is a welcome change
from the norm. If the family wants to know why the interview is necessary, a useful
response is "so that you, as a family, can help me, as a physician, better understand
the medical problems that brought 'X' to the hospital."
If the patient is seen in the office, a family interview is more difficult to achieve.
The physician has very little leverage in the office setting. Patient acceptance of
family participation depends upon the degree of ambivalence the patient feels about
facing the chemical problem. In early cases, where the personal consequences of the
chemical use are less severe, patients may be relatively eager to resolve their conflicts.
In later, more fully developed chemical dependency, the physician may have to wait
for an appropriate therapeutic moment to intervene. Such dilemmas will be discussed
at the end of this protocol.
In many instances, the physician's first contact may be a spouse or child of the
chemically dependent person. In this case, the initial task may be to help this patient
connect with a community support system for family members, such as Al-Anon
or special co-dependency educational or treatment programs. Months or years may
pass before the family member contacts the recommended community resources.
During this time, it is useful for the physician to remain supportive and to refrain
from pressuring the patient to seek more powerful assistance.
With support and education, family members may come to appreciate how they
can be helpful in confronting the chemically imparied person. The Johnson Institute
in Minneapolis, Minnesota, pioneered the technique of training families to plan and
carry off powerfully confronting family interviews, which lead directly to formal
chemical dependency treatment (7). When such resources are not available or feel
inappropriate to the family, then a less aggressive approach toward family recovery
may be initiated. However, to wait for spontaneous improvement is to deny the
reality of the disease.
Step 4. Interview the Family
In a previous issue of Family Systems Medicine, the techniques of interviewing
families with compliance problems in general were presented (2). This protocol is
a special case of a compliance issue, but follows the more general outline. The

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specific points that relate to chemically dependent patients and their families are
listed below.
1) Discuss the objective medical problems first. This is usually comfortable for
both the family and the physician. Encourage questions to ensure that this level of
information is understood by the patient and the family.
2) Ask for input as to what family members think may contribute to these medical
problems or to the conflicts that led to seeing the physician. Don't expect quick
responses. This interview may be the first time that the family has been offered the
chance to say something to each other about the "family secret," not to mention
to a health care professional. If drug or alcohol use has created conflicts within the
family, this is the family's opportunity to verbalize their concerns.
If no one mentions drug or alcohol use, either the problem does not exist or it
is too threatening to discuss. In the latter case, the physician must decide whether
or not to mention the taboo topic. If the physician decides to open a discussion of
the abuse, the likely outcome will be vehement denial by the person using or abusing
chemicals, temporary relief by some family members, and a quick end to the family
interview. Sometimes, there is no other choice but for someone in the "system" to
speak the forbidden words. However, an alternative option is to offer continued
support and to plan another family interview. This option is based on the belief
that eventually, someone within the family will take the responsibility for initiating
change.
3) Once the topic of drug or alcohol use is open for discussion, the physician
should ask, "What is it like to be in this family?" Each person in the family must
be allowed to respond to the best of their ability. Sometimes the silent members
will hold out until late in the interview to express anger toward the drug problem,
or toward the physician, and/or toward family members who want to discuss the
issue.
4) Avoid discussions of how much of the drug or alcohol is used by the chemically
imparied patient (3). Initial statements are usually inaccurate, even by highly motivated patients. Remember that a major symptom of the chemical abuse is denial.
Since no treatment has yet been employed, one would not expect the symptom
(denial) to disappear during the first interview.
5) Focus on the consequences of the drug/alcohol use for other family members.
Typical consequences are frequent family arguments, broken promises, social embarrassment that leads to avoiding the home or the chemically imparied family
member, financial crises, unmanageable medical problems, and depression for family
members and the chemically dependent person.
6) The physician and the family must come to some agreement on the severity
of the chemical problem. If it is a serious problem, then a major treatment effort
is indicated. If only a minor problem exists, as estimated by the consequences of the
drug use or behavior associated with drug use, then perhaps observation is warranted. However, this evaluation should involve someone experienced with chemical
abuse/dependency. Often, the initial interview leads to the family's agreement to a
professional in chemical problems being asked to interview the patient and family
in order to assess the severity of the problem.
7) Avoid suggesting abstinence or "cutting down" on drug or alcohol usage as
the sole treatment option. This is the most common error. In fact, this well-intended,
ineffective action by physicians is the current norm. If a serious chemical depend-

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219

ency/abuse problem is diagnosed, then potent intervention is indicated. Family members need support from self-help groups such as Al-Anon and Alateen. The
chemically dependent person can also benefit from talking to others who have faced
the same problem. The most reliable contact for this is Alcoholics Anonymous (AA)
or Narcotics Anonymous (NA).
Counselors and family therapists trained in working with chemical dependency
are available, and inpatient and outpatient treatment centers are located in nearly
every city and are usually accessible from rural areas. There are many options. But,
the patient's desire to "work on this alone" is a poor treatment plan. It is not helpful
to reinforce this attitude by simply asking someone to "stop drinking" or "stop
using" without offering concrete assistance.
8) Offer reading materials from AA, NA, Al-Anon and Alateen. Many materials
are available from both local and national resources.
9) If no direct referral is made at the time of the family interview, then the
physician should give the patient the phone numbers of the local chemical dependency resources. (I always keep these and other resource numbers in my coat pocket,
opposite my stethoscope.)
Step 5. Be Honest
If the family interview confirms a diagnosis of chemical dependency, chemical
abuse, suspected alcoholism, or alcoholism, then the physician must record the
diagnosis on the office or hospital chart! If we deny the problem by avoiding the
use of realistic diagnostic terms, how can we expect the patient and family to come
to grips with this probelm?
CONCLUSION
When dealing with a disorder in which the patient's denial is paramount, there
are limits to what any physician can accomplish. We can be helpful in many ways:
We can provide literature about drug and alcohol dependencies, and make direct
referrals to local treatment centers, counselors, family therapists who work with
chemically dependent families, AA, and Narcotics Anonymous. We can offer our
continued support. We can communicate genuine respect for the patient, even when
there is disagreement about the next step in the treatment. However, some patients
continue to use alcohol or other drugs in a self-destructive way, despite the best
efforts of physicians, friends, and the patient's family. Accepting this limitation is
an important part of remaining helpful.
When confronting chemical dependency/abuse, the physician may not see immediate changes. Many patients will return at a later date to ask for more assistance
or will someday seek help from another source. Even if the primary physician never
learns the outcome for a specific patient involved in a confrontation, that physician
has honestly struggled with a difficult and painful problem while communicating
respect for the integrity of the patient. The responsibility for change has been returned to the patient and the patient's family. The interaction process has been
sound and is more apt to lead to constructive change than a process in which the
physician becomes overly responsible.

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This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

By using this protocol, I have found that interacting with chemically dependent
or chemical-abusing patients and their families is a rewarding and satisfying experience. These patients and their families are courageous in seeking change. With
an investment of 60-90 minutes for a family interview, it is possible to begin a
process that may have positive influence on one, two, and sometimes, three generations of a family. The chemical dependency treatment system carries most of the
treatment responsibility, as well as credit for any ultimate helpfulness. However,
I take pride in being an early member of this team.
REFERENCES
1. Doherty, W. J., & Baird, M. A. Family therapy and family medicine. New York: Guilford
Press, 1983.
2. Doherty, W. J., & Baird, M. A. A protocol for family compliance counseling. Family
Systems Medicine, 1984, 2(3), 333-336.
3. Gitlow, S., & Peyser, H. Alcoholism: A practical treatment guide. New York: Grune &c
Stratton, 1980.
4. Journal of the American Medical Association, 1984, 252(14).
5. Niven, R. G. AlcoholismA problem in persepctive. Journal of the American Medical
Association, 1984,252(14), 1912-1914.
6. Stephens, G. A decalogue for the management of alcohol and drug abuse. Editorial:
Continuing Education for the Family Physician, 1984, 19(3), 125.
7. Wegescheider, S. Another chance: Hope and help for the alcoholic family. Palo Alto:
Science & Behavior Books, 1981.
Macaran A. Baird, M.D.