COST-BENEFIT OF THE SYSTEMIC FAMILY THERAPY OF ALCOHOLISM: IS IT REALLY ECONOMIC APPROACH?*
Abstract Macedonia passes through their hardest period of the political and social transition. Consequently, the asocial and antisocial activity and insecure of people as well as increased addictive disorders. The consumption of alcoholic beverages in the society, especially among youngsters, is also concerning for the years. At that point, the treatment approaches of alcoholism in Macedonia have a specific history passing from medical to the Eco-systemic. The expenses related to the treatment of alcoholism can be valued as enormous. It seems that the most effective and cheapest appears to be the last one.
BACKGROUND Republic of Macedonia is a newborn country constituted as an independent country after the dissolution of the former Yugoslavia in 1991. Currently, Macedonia is passing through its hardest and painful political, economic and social transitional process. The specific indicators referring to the individual and social endangerment should be the quantity of alcoholic beverages consumed and the number of treated people suffered from alcohol addiction or other collateral damages from, too. The treatment approaches of alcohol addiction in Macedonia have a specific history. In the 70-ties of the past century, this addiction was seen typically as individual pathology only and approach as medical. The expected final treatment outcome was abstinence itself, ranged from 4-6%. Meanwhile, the socio-psychiatric scope on the problem has arisen at the beginning of 80-ties. It was a period when the so-called Clubs for Treated Alcoholics were introduced. They were understood as a triumph of the alcoholic’s post treatment care of former socialistically organized society. Following the medical stream of the treatment approach to the alcohol addicted, the therapy target has been focused at the abstinence itself, and the organic, social and psychological aspects of the problem as well. This treatment approach was described as expensive and better than previous medical treatment model. But, still insufficient. It was a reason why Disulfiram was widely introduced last 3 decades, both oral and implanted. (Only to mention here that we have perfect experience with the Disulfiram-implantation having more then 8200 alcohol dependents operated last 3 decades). The main characteristic of the admitted alcoholics that time was the chronicity - meaning heavy organic, psychological, family, professional, and social damages which need long-term treatment with unclear outcome, frequent relapses, more specialists’ engagement and lot of money spending. The quantity of hospital's facility occupied by alcoholics was increased. Money spent for treatment of alcoholics is lost money, is the common public opinion in Macedonia. From the other side, the family of alcoholics, or better said, the alcoholic family, that time was seen as a cotherapist only, and neglected from the treatment process. Although this socio-psychiatric approach was socially and group oriented (the most popular treatment method is the Therapeutic Community), it has offered abstinence and health improvement ranged from 20-30% in one-year follow up period. This treatment model, less or more, is still on scene but preferably medical. Later in the 80-ties, the ongoing development of knowledge has provided an additional influence on the Macedonian alcohology. After the group of Macedonian psychotherapists has been educated and trained in Belgrade systemic family therapy school our first systemic oriented family therapy program was introduced and established. It was happened in 1988. In addition, after the first doctoral dissertation in systemic family therapy field was defended 1997, the interest in this psychotherapy approach to family and family therapy has markedly increases among the psychotherapists. When introduced, we have realized that our first program was something best happened to us. The expenses related to the treatment of alcoholism in Macedonia can be valued as enormous. If all the expenses for correction of social, legal, professional, health and other unregistered consequences are added, the total costs will dramatically increase. In addition, there is no general agreement between politicians, medical and social workers about which side of the problem is more tolerant: taxes gained by producing and consuming of alcoholic beverages (meaning - more produced and more sold alcohol, more money for the governmental budgets), or damages from alcoholism itself. Taking in considering the extension of the problem and total mental hospital facility occupied by alcoholics’ (128), we could say that Macedonia has good developed health services and sufficient inpatient and outpatient facility available. An additional, Day hospital facilities are ranged up to 80 "beds".
DISCUSSION According to the basics of the systemic approach, alcohol addiction is not a separate individual pathology. The alcohol addicted person itself as a "chosen" bearer of the deeper and hidden family pathology that acts in the background (The "Index-patient"). Playing specific transactional "games", the family members equally participate in both maintenance and developing of alcoholism. It consequently causes disorder of family communication, and vice versa. In fact, drinking and drunk behavior should be understood as a specific transactional stressful maneuver by which alcoholic establishes control over all family relations. Distorted communication contributes to the development of alcoholism, and alcoholism itself contributes to the development of distorted communication and consequent stress. At that point, the ultimate treatment goal is entire dysfunctional family system the stressful family relations (the "Second Order Change"), but not the abstinence itself, a symptom of the hidden family pathology (the "First Order Change"). Very simplified said, "The First Order Change" is system’s functioning change when only the symptom of deeper and hidden family pathology is eliminated (i.e. drinking alcohol itself as a symptom of hidden family pathology). A "Second Order Change" is system’s functioning change when the entire family relations, communication and functions have been changed in a more functional level, as well.
PROCEDURES Method & Instruments In order to evaluate the real, but not only the assumed potency of the Systemic family therapy approach to improve the quality of life of alcoholic family, a group of 79 selected families in "Life Stage 5" were treated in a one-year systemic family therapy course. They were asked twice to fill-in the appropriate questionnaires: The FACES III of the Circumplex Model of Family Functioning instrument, Olson, D.H., 1985 (Figure 1), and the Marital & Family Conflicts, etc.)*, at the beginning and at the end of course. Data collected were statistically assessed. The Circumplex Model of Family Functioning (Olson, D.H., 1985)© is an graphical model that allows families, couple and family members to be distinguished into 3 separate functional types after the separate mathematical assessment of items listed in the FACES III questionnaire ("Family Adaptability and Cohesion Evaluation Scales - Third Revision): "closed" (dysfunctional, extreme), "traditional" (mid-ranged), and "open" (balanced, functional).
Figure 1. Circumplex model of family functioning (Olson D.H., 1985) (click pentru imagine)
Figure 2. Circumplex model of family functioning (Olson D.H., 1985) (clic pentru imagine)
The model also allows each family, couple and member to be plotted in one of the 16 fields on the model grid being functionally closer described. The instrument is easy to use and perfect for the research purposes. Participants The average marriage duration of the participants was 10.9 years; that of the husbands was 37.3 years; of the wives 34.2 years and 14 years of the adolescents. Most of the families (64 i.e. 81.0%) lived in a "nuclear" family extension and the majority of the alcoholic husbands (55 i.e. 69.6%) had their high school education completed. The average duration of alcoholism was 16.6 years.
RESULTS AND DISCUSSION We found that almost half of the families assessed, 38 (48%), have showed markedly stressful dysfunctional "closed" family system, and all the group have been averaged as being "Chaotically Disengaged" before the treatment course (Figure 3). Shortly, it suggests that all family tasks, relations and communication have been dysfunctional and family suffered.
Figure 3. Circumplex model of family functioning (before the treatment) (click pentru imagine)
Figure 4. Circumplex model of family functioning (after the treatment) (click pentru imagine)
Table 1 (click pentru imagine)
After the one-year treatment in the systemic family psychotherapy course, only 8 (12%) have remained at that functional position after the treatment, and 30 families have gained better positions onto the model grid. It exactly means that the so-called "The Second Order Changes" of family functioning have been therapeutically reached in 78.78%, the best results ever seen before in Macedonia. It means that alcohol intake was stopped and referent family’s relations have been optimally rebuilt at a functional level (Figure 4). The average statistical significance of changes has been ranged from p < .005 to p < .0001. It should be good to underline here that no special equipment, no medicines, no tranquilizers or sedatives or special facility are needed, but excellent educated, trained and supervised psychotherapists only. The hospitalization is not needed, too. Considering the expenses we are talking about, it need two current treatments approaches in Macedonia to be compared in simplest way: The medical, and The systemic psychotherapy treatment model. The referent years taken for this purpose are 2000 (for hospitalized alcohol addicted clients - the most recent figures) and 1991 for the group systemic family psychotherapy, a year full employed with group sessions (table 1). Expenses: _ In-Patients = 18.18 USAD/per day: facility & medicines; _ Day/out patients = 15.00 USAD/per day: facility & medicines; _ 1 Session (1 hour per family) = 12.7 USAD facility, no medicines. _ Teams’ (psychiatrists, psychologists, Social Workers, Occupational Therapists, Auxiliaries) salary, taxes, and additional costs not included. Health Insurance should pay that (virtual) money to the psychiatric health institutions in accordance to the price list signed. In reality, the amount paid extreme varies depending on objective and non-objective reasons.
CONCLUSION Characteristics of the Socio-psychiatric model (preferably medical)
-- large hospital facility is occupied, both inpatient or day facility;
--mental intramural hospital treatment that stigmatizes;
-- 24 hours treatment a day, 7 days weakly, for a unknown duration;
-- clients are treated separately;
-- long-term treatment usually needed;
-- large professional team is immediate employed;
-- expensive detoxification procedures applied;
-- sedatives, tranquilizers and other medicines of large amount used;
-- high percentage of early relapses occurred;
-- high percentage of re-admission in a residential facility;
-- no optimal functioning of the entire family achieved;
-- abstinence as final therapy outcome is expected (but in low percentage achieved);
-- high expensive. Characteristics of the Systemic model (excluding medical)
-- hospital facility not needed;
-- extramural treatment facility;
-- families (clients) are treated in group setting;
-- 2-4 time monthly sessions, 3-4 hours per session in same place and time;
-- 2-3 professional team members (psychotherapists) occupied;
-- no detoxification procedures applied;
-- no sedatives, tranquilizers and other medicines usually needed (except Disulfiram for one year);
_ low percentage of drop-outs from the program (not always because of relapses);
-- no re-admissions (re-admissions not needed);
-- optimally family functioning including strict abstinence achieved;
-- high percentage of long-term sobriety (more than ten years) occurred;
1. Annual financial & statistical 2000 report of the Psychiatric Hospitals.
2. Ackerman, N. (1967) Prejudice and scapegoating in the Family. In: Zuk, H.G., and Boszormenyui-Nagy, I. (Eds.): "Family Therapy and Disturbed Families", Science and Behavior Books, Inc., Palo Alto, California, 41-47.
3. Bowen, M. (1974) Alcoholism as Viewed through Family Systems Theory and Family Psychotherapy. Ann. N.Y. Acad. Sci., 233, 11.
4. Glik, D.I., Kesslerr, D.R. (1980) Marital and Family Therapy. Sec. ed., Grune and Stratton Inc N.Y., London, Toronto, Sydney, San Francisco.
5. Olson, D.H., Sprenkle, D.H., Russell, C. (1979) Circumplex Model of Marital and Family Systems Cohesion and Adaptability Dimensions, Family Types and Clinical Applications. Family Process 18: 3-28.
6. Stanton, D.M. (1991) Strategic Approach to Family Therapy. In: Gurman, A.S., and Kniskern, D.P. (Eds.): "Handbook of Family Therapy", Vol. II, Brunner / Mazel, publ. N.Y.
7. Steinglass, P. (1986) Experimenting with Family Treatment Approaches to Alcoholism 1950-1975: A review. Family Process, 15:97-123.
8. Steinglass, P., Benett, L.A. (1987) The Alcoholic Families Basic Books. New York.
9. Steinglass, P., Weiner, S., and Mendelson, J.H. (1971) A Systems Approach to Alcoholism: A model and Its Clinical Application. In: Gacic, B.: "Porodicna terapija alkoholizma", RAD, Belgrade, Arch. Gen. Psych., 24: 401.
10. Vidinovski, P., Vidinovski, F., Zaovska, J. (1994) Alcoholic Family Functioning v. Family Strengths: Is There Any Correlation Between. Proceedings of the ICAA, Prague.
11. Vidinovski, P. (1996) Changes of Communications in Alcoholic Families during the Systemic Family Therapy of Alcoholism. Doctoral Dissertation. 12. Vonnegut, K. Jr. (1980) Breakfast of Champions. N.Y.Dell, 1973, pp. 256-257, in: Glik, D.I., Kesslerr, D.R.: "Marital and Family Therapy", sec. ed., Grune and Stratton Inc N.Y., London, Toronto, Sydney, San Francisco.
* Third WPA Regional Meeting: Financing Mental and Addictive Disorders in Central and Eastern Europe, Bucharest, November 23-25, 2001
** Primarius Pande Vidinovski, MD, Ph.D, psychiatrist, sup-specialist for addictions. Family therapist and International Family Therapy Association Board member. Head of the day Hospital for Alcoholism in Skopje, Republic of Macedonia * Third WPA Regional Meeting: Financing Mental and Addictive Disorders in Central and Eastern Europe, Bucharest, November 23-25, 2001
*** Primarius Pande Vidinovski, MD, Ph.D, psychiatrist, sup-specialist for addictions. Family therapist and International Family Therapy Association Board member. Head of the day Hospital for Alcoholism in Skopje, Republic of Macedonia.