|Year : 2016 | Volume
| Issue : 1 | Page : 7-14
Substance use disorder and the family: An Indian perspective
Siddharth Sarkar1, Bichitra Nanda Patra2, Shivanand Kattimani3
1 Department of Psychiatry, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India
2 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
3 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Web Publication||22-Dec-2015|
Department of Psychiatry, Sree Balaji Medical College and Hospital, #7, Works Road, Chrompet, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
The substance use disorder not only impacts the patient himself/herself, but also affects family members. This is more relevant in a country like India where the familial ties are stronger with family members playing a significant role in the treatment process. This narrative review takes an overview of the inter-relationship between substance use disorder and the family. The domestic violence and adverse familial circumstances, both often arise as a consequence of substance use. Although the spouses of substance users experience greater rates of psychopathology and distress, children of patients with substance user disorders demonstrate higher levels of behavioral disturbances. Codependence often develops in the familial relationship, which perpetuates the substance use disorder. Substance use places quite a burden on the family, both psychologically as well as in terms of resources. Nonetheless, family members provide motivation, emotional support, and practical help during the treatment of substance use disorders and hence need to be engaged in the therapeutic process. Finally, the changing family structure and family dynamics in India might influence the in the future both the effect of substance use disorder on the family, and the familial resource available for treatment.
Keywords: Alcohol, family, opioids, spouses, substance use, treatment
|How to cite this article:|
Sarkar S, Patra BN, Kattimani S. Substance use disorder and the family: An Indian perspective. Med J DY Patil Univ 2016;9:7-14
|How to cite this URL:|
Sarkar S, Patra BN, Kattimani S. Substance use disorder and the family: An Indian perspective. Med J DY Patil Univ [serial online] 2016 [cited 2020 Aug 9];9:7-14. Available from: http://www.mjdrdypu.org/text.asp?2016/9/1/7/172413
| Introduction|| |
Substance use disorder is often considered a family disease.  Substance use not only affects the substance user, but also affects the family members in many significant ways. In addition, some family members develop ways of behavior that can perpetuate substance taking. Nonetheless, family members can also serve as support systems that can be of immense help in the treatment of the substance use disorder.  Substance use influences the family members in complex ways.  Understanding this relationship can help in addressing the problem of substance use disorder more effectively and planning services accordingly. 
Differences exist between India and the other Western countries in the familial structure and outlook. Unlike the Western society which gives much importance on individual autonomy, Indian society still lays a lot of importance on familial bonds,  though the situation might be gradually changing in the recent years. Divorce rates in India are quite low compared with the Western developed countries, and spouses continue to remain in the relationship despite facing a considerable degree of marital strife. The concept of personal "space" is rather limited in India and enmeshment is frequently seen among familial relationships. Moreover, the health services and social support systems are quite different in India. A large proportion of health care is provided through noninsured out-of-pocket payments, and overall health-care services are quite fragmented. In this context, family members in India frequently provide support for treatment, and also help in tiding over phases of the financial crisis.
India being a diverse country and housing the second largest population in the world presents a large caseload of substance users due to sheer numbers. Substances of use, especially alcohol has shown increasing production and consumption indices in India with the onset of drinking occurring at much younger age, , attesting the growing problem of substance abuse. Hence, it is of interest to understand the various facets of the relationship between substance use disorder and the family in the Indian context. This review discusses the relationship between substance use disorder and family in the India. Relevant literature from across the world is highlighted, followed by Indian literature wherever available. The authors acknowledge that the present review reflects one of the perspectives, and many other ways of conceptualizing the relationship between the substance use disorder and family may exist.
A typical case example of substance use and the effect on the family is depicted in Box 1.
| How Does Substance Use Affect the Family?|| |
Substance use affects the family in a variety of ways [Figure 1]. Broad themes are discussed further though one needs to acknowledge that families differ in their structure, composition, their power dynamics, moral and societal outlook, and position in the society. The effect of different substances in the family context may vary. These factors determine the manner in which substance use affects the family. The situation of each substance user and each family member may be unique. Cognizant of the caveat, how substance use affects the family is broadly analyzed.
Domestic violence has often been linked to substance use, especially the use of alcohol. The instances of domestic violence may vary over time, and can involve physical, sexual and emotional abuse. Such violence may include instances like hurting the spouse under intoxication, or snatching the money/jewelry for the continuation of the substance taking behavior. Meta-analytic studies have found that the alcohol use disorder has been consistently associated with intimate partner violence.  Such violence has been linked to heavier alcohol use in the husband, more frequent alcohol use and greater the severity of the alcohol use disorder. The overall effect sizes have been small to medium, suggesting that may other factors may play a role in mediating the relationship between alcohol use and domestic violence.
Data from India also suggests that alcohol use has been associated with spousal violence. The National Family and Health Survey III, a nationally representative study that surveyed about 70,000 women aged between 15 and 49 years found that 31% of the women experienced physical violence in last 1-year. Logistic regression analysis found that husband's alcohol use was associated with greater odds of reported violence among the women.  Findings from the urban slum and economically poor areas also suggest that spousal violence was more common in families where the husband used or abused alcohol. , The cultural context varies with respect to the manifestations of alcohol associated domestic violence. , Apart from dowry issues, husband's drunkenness has been reported to be associated with domestic violence toward the spouses in India. In addition, many other factors including economic pressures and inter-generational exposure to violence have been reported to be associated with domestic violence.
Various theoretical models have been proposed to explain the association between alcohol use and interpersonal violence.  The first model is of spurious association which suggests that both alcohol use and violence are independent of each other and are associated with other common risk factors like age and other deviant behaviors. The second model of indirect effects suggests that alcohol use has a causal relationship with domestic violence mediated through marital conflict and dissatisfaction. The third, proximal effects model suggests that alcohol intoxication facilitates aggression through distorted perception of cues and lowering of inhibitions. Over time, more evidence has gathered for the indirect effects and the proximal effects models.
Though alcohol use has been robustly linked to spousal violence, evidence linking drug abuse to such violence is less strong. A multiethnic study from the United States involving about 1600 couples did not find any relationship between use of drugs and intimate partner violence though alcohol use was associated with such violence.  Similarly, other studies have found less firm link between drug abuse and spousal violence.  The only Indian study assessing intimate partner violence among wives of patients with opioid dependence found that the rates of violence was lesser in opioid dependence group than the alcohol-dependent group.  Violence was associated with older age of the husband, lower education, unemployment of either spouse, lower family income and a nuclear family structure.
Family member stress and burden
Some of the studies have evaluated caregiver burden of substance use disorder among family members. Substance use has been reported to be associated with a considerable burden on the family members. , The burden on the family members has been found to be higher where the substance user has a greater severity of the substance use disorder or has poly-substance abuse.
Among Indian studies, an assessment of burden among family members of alcohol and opioid dependent men found that the global burden was rated as moderate or severe in more than 95% of the family members. The burden did not differ across the substance groups but was more among family members who resided in rural areas.  Another study found that the family burden was more among injecting drug users than noninjecting drug users.  Similarly, spouses of opioid dependent treatment seekers were most commonly graded to have a higher burden both objectively and subjectively. 
A presence of dual diagnosis, that is, co-occurring substance use disorder and mental illness extracts greater caregiver burden and stress on the family members than a single disorder. This stress is associated with higher degree of patient's behavioral problems and a lesser degree of available support systems. , Patients with both mental illness and substance abuse have a poorer familial relationship than patients with the only mental illness. 
Psychiatric symptoms among family members
Family members of substance users have been seen to have greater rates of psychopathology than relevant controls. Spouses of alcohol-dependent men had higher rates of depression than wives of former drinkers.  Alcohol use among husbands has also been related to physical symptoms like headaches, lower psychological quality-of-life measures and presence of mood and anxiety symptoms. ,,
Indian data suggest that spouses of alcohol-dependent men had a greater number of suicide attempts, which was often related to the delusion of jealousy and fighting behavior of husbands.  A recent study among spouses of alcohol and opioid dependent men from Northern India found about one-fifth of them were suffering from psychiatric illness.  Depression and dysthymia were the most common psychiatric diagnoses present in these spouses of alcohol and opioid dependent men.
Effect on children
Children represent another vulnerable group of individuals who are predisposed to be affected by parental substance use. Historically, four distinct roles adopted by children of alcoholics have been described : t0 he hero, scapegoat, lost child, and mascot.  The hero is a responsible child who puts in hard work to be the best. The scapegoat is the child involved in delinquent activities and who breaks rules. The lost child tries to desist away from attention while the mascot attempts to use humor to deal with the situation. Parenting styles of alcoholic parents may induce psychological distress in the children and result in poor self-esteem. ,
Alcohol use in parents is associated with more disruptive behaviors, externalizing disorders, lower social competence, earlier onset of a substance use disorder, negative emotionality and low self-regulation in the children. , Parental substance use has been associated with not only externalizing disorders, but also internalizing disorders like depression and anxiety.  Studies from India have also suggested children of men with alcohol dependence have more externalizing and internalizing behaviors on when compared with controls,  and a greater degree of behavioral problems. 
Substance use disorder is often considered a stigmatizing condition, probably due to its association with delinquent activities, and presence of other stigmatizing health conditions like HIV. Family members of the substance user are also likely to face courtesy stigma, due to being in association with the substance user. Stigma experienced by family members can depend on many factors like behavioral problems exhibited by the substance user, incarceration due to behavioral problems, the extent of the substance use problem, and overall social support. 
Indian data on stigma among family members is relatively restricted. It has been seen that the perceived stigma toward substance use was similar between patients with the substance use disorder and their family members.  The study also found that perceived stigma was similar between spouses of alcohol and opioid dependent patients and that unmarried family members were likely to perceive a greater degree of stigma.
Codependence refers to a concept in which close relatives of the patient adapt to substance use in a manner that facilitates the continuation of substance use. The construct involves inter-relationships of dynamics of caretaking, personality characteristics, psychosocial condition, and interpersonal style of the individual. , Presence of codependence impairs the quality of life of the codependent person, and is associated with low self-esteem, dependency, depression and anxiety, anger, fear of rejection, increased use of substances, and stress-related difficulties. By prolonging the substance use behavior, such a relationship may intensify the substance related complications over time.
Indian literature on codependence suggests that husbands' duration of substance abuse, employment-related complications and coping among the wives were independent predictors of codependence among the spouses of alcohol-dependent men.  Another study assessing codependence among spouses of alcohol and opioid dependent men found that "fear," "shame" and "impaired identity development" were the most common codependence characteristics endorsed,  whereas "denial" and "prolonged despair" was encountered less frequently. Younger age of the spouse was associated with greater chances of being in a codependent relationship.
Financial resource drain
Substance use disorders may take away a substantial proportion of family income and thus pose a significant financial burden. The financial stress on the family is caused not only by the money spent on the substance of abuse, but is also compounded by the loss of potential income and expenses related to health impairment. Regular substance use may lead to substantial debts, further resulting in loss of assets to repay the debt. Loss of employment of a substance dependent breadwinner can be a grave challenge for the family in India due to the lack of social security benefits for the unemployed. Family members might need to seek help from other distant relatives for financial support in such circumstances, even to meet basic expenses. Financial insecurity may result in worry and stress-related problems among the spouses and children. Familial financial difficulties can lead to lowered self-esteem among the children and may impel them to resort to delinquent means to fulfill their material needs.
Family antecedents to substance use
Not only is family affected by substance user, but characteristics of the family can predispose an individual to develop a substance use disorder. Lower parental support and structure has been associated with youth alcohol use.  Family conflict is one of the important predictors of alcohol use initiation, suggesting that adolescents in families with greater conflicts are predisposed to develop the substance use disorder.  Furthermore, work-family conflicts have been associated with increased alcohol use among both men and women. 
There seems to be some degree of familial and social learning for substance taking behaviors. Many cultures are permissive about the younger generation taking alcohol but in a supervised and controlled environment. However largely, Indian families abhor the use of alcohol in the house on a regular basis along with meals, and segregated consumption of alcohol is tolerated on certain occasions/functions. Similarly, use of cannabis has been considered relatively acceptable during the occasions of special festivals of Holi and Shiva Ratri. Use of opioids has also been ethnographically acceptable in North-western India in smaller amounts, often as a home remedy for certain ailments.  A family member taking a substance removes the proscription attached to it. One the other hand, seeing a family member experience "bad" effects of a substance may generate disgust and deter experimentation. The family may offer social learning for both the use of substances as well for aversive attitudes toward substance use.
| Family as a Support for Treatment|| |
Family members play a crucial role in the treatment of a patient suffering from a substance use disorder in India. Generally, a substance user seeks treatment in the West by his/her will. However, in India, often the family members take a patient to the hospital for treatment, often forcefully against the patient's explicit wishes. They also ensure that the patient adheres to treatment. This may be one of the reasons of the efficacy of disulfiram being better in Indian studies when compared with other medications for the treatment of the alcohol use disorder. , Family member's wishes are often an important consideration in decision making in the Indian health-care system, and their involvement in the treatment process is regarded well.
Family members provide support for treatment of the substance user in many practical ways. The family members find out about the locations of treatment centers, the costs and procedures involved. They accompany the substance user for treatment, and at times reside with the patient for the initial detoxification phase. They may arrange for the patient to stay in the rehabilitation center despite patient's explicit wishes to ensure abstinence. The de-addiction services in India are attuned to the involvement of family members in the care process.  Family members when residing in close quarters with the patient often provide "nagging," which may change the motivational status of the patient from precontemplation to contemplation or action phase. They help in ensuring adherence to the treatment, especially with regards to supervision for disulfiram and naltrexone. They may provide "company" to ward off substance using peers. They may encourage abstinence-oriented religious observations like Navratra and Ramzan when substance use is proscribed. Finally, family members provide refuge to the patient in the times of crisis and prevent them from becoming "homeless" as a consequence of substance-using behavior. Since family provides support in so many ways, their help should be utilized in the treatment process, and due regard should be given to their concerns.
The evidence base has accrued of involving family members for the treatment of patients with substance use disorders. Community Reinforcement Approach and Family Training (CRAFT) is a behavior therapy approach for patients with substance use disorders that combines the CRAFT.  This approach is focused on family members with the aim of helping the substance user engage in treatment and reduce the substance use, as well as improve the life of family members. Several strategies are utilized to achieve this goal including providing positive reinforcement and developing positive communication. The approach has been proven useful for engaging resistant substance users and has demonstrated superior efficacy compared to Al-Anon or Nar-Anon, a 12 step based intervention for family members of substance users.  "The Intervention," also referred to as the Johnson Institute Intervention is a process wherein the important persons in the individual's life gather to communicate their concerns in a nonjudgmental manner. The substance user is given specific choices for treatment, and as he/she agrees for it, help is provided immediately. A Relational Intervention Sequence for Engagement (ARISE) is another approach that is a manual-based intervention for engaging difficult to treat substance users. This intervention begins when a concerned family member calls up the treatment services for a substance user. The sequential aims of this treatment are to build a network, coaching the concerned family member to arrange a meeting with significant others, inviting the substance abuser, and subsequently conducting an "Intervention."  The efficacy ARISE has been demonstrated, with more numbers of significant others involved better associated with outcomes.  The CRAFT and ARISE approaches described above have some differences. While CRAFT is more assertive "coaching" approach, ARISE is a sequential approach based upon the extent family members are able to follow through the strategies. While CRAFT encourages family members to improve their lives simultaneously, such a specific focus is not present for ARISE. The above-mentioned interventions may need some modification in the Indian context due to differences in cultural and health-care delivery.
| Changing Family Dynamics in India: How Does it Affect the Family of Substance User?|| |
Indian society has been transitioning from traditional joint family system to more individualized nuclear family set-up. This has led to changes in the family dynamics, which might have implications in the inter-relationship of substance use and the family. Previously, a typical traditional Indian family was a joint family, with the head of the family being held in unquestioned regard. The authority would be hierarchical, and there were limits to independence. The authority wielded power, but also served as a role model. The role of family members was well prescribed. The family was more cohesive, and family members would show concern for each other's welfare.
However, in the transitioning Indian society, families are becoming more fragmented. Nuclear families are becoming more common with a consequent decline in available social supports. The authority structures are changing with power differentials being at a variance than previous times. More women are in formal employment nowadays, providing more resources for the family but having the additional stress of juggling many responsibilities. Lesser number of children per couple in the present day context may be associated with children being pampered more and disciplined less frequently, which might result in them experimenting with substances with minimal apprehension of being taken to the task.
The changing family dynamics of Indian society might affect substance user's family as well. With less number of caregivers per family, caregiver stress might increase because of dealing with the substance user single-handedly. Less number of family members is likely to translate into lesser opportunities of diffusing worry and anxiety through social supports. Furthermore, one or few family members may feel burnt-out caring for the patient as the substance use disorders are typically chronic conditions with multiple relapses. With less frequent authority figure in the household, substance-related domestic violence might also increase. However, women empowerment with more assertive and independent decision making, may allow spouses to stand up against any abuse and hence deter domestic violence arising out of substance use.  A less hierarchical authority in the current family systems may mean more opportunity for the patient to decide against the treatment. Hence, familial persuasion toward treatment might become less frequent in the future, and more emphasis may lay in the autonomous decision of the patient.
| Conclusion|| |
Family members are affected by substance use disorders to a large extent in various ways. This might be more applicable in societies like India where the families are close knit. Family members also provide crucial social support in the treatment of substance use disorders, and their role needs to be acknowledged and respected. Changing social structures in recent times can have an impact on the effects of substance use disorders on the family, as well as the role of the family in the treatment-seeking process.
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Conflicts of interest
There are no conflicts of interest.
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