Transcript FAMILY AND NETWORK INTERVENTIONS IN ADDICTION: THEORY …

Family Interventions &
Evidence Based
Approach for Helping Families
Prof Alex Copello
Consultant Clinical Psychologist
Addiction Services
Birmingham and Solihull Mental Health Foundation NHS Trust &
Professor of Addiction Research
The University of Birmingham
[email protected]
Presented at: Recovery & Reintegration Event - 20th July
2010, Belfry, Cambridge
Addiction and the Family
Plan
► Acknowledgements
► Why
families matter
► Impact of addiction problems on
families
► What do we know from research on
interventions?
► What happens in practice
► Some conclusions
ADDICTION AND THE FAMILY (ADF) GROUP
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The University of Birmingham/Birmingham and Solihull Mental Health
NHS Trust Substance Misuse Service
Jim Orford
Akan Ibanga
Alex Copello
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The University of Bath Mental Health R&D Unit/Avon & Wiltshire
Mental Health Partnership NHS Trust
Lorna Templeton
Richard Velleman
….and numerous other colleagues who have been part of this group over the
years both in the UK and other countries.
…it ought to be both surprising and shocking
that there has been so little in the way of a
co-ordinated response to families living with
the drug problem of their son or daughter,
brother or sister.
Marina Barnard
Drug Addiction and Families
2007, p. 51
During the past 3 decades, there has been increased
recognition from researchers of the key role that
families can play in substance misuse treatment, in
terms of:
► preventing
and/or influencing the course of the
substance misuse problem
► improving substance-related outcomes for the user
► helping to reduce the negative effects of substance
misuse problems on other family members.
[Copello, Templeton and Velleman, 2006]
What do we know from
research?
Impact
Substance misuse is associated with
a range of social and health problems
affecting the individual as well as the
family within which the individual
lives
Orford, Natera, Copello, Velleman,Templeton et al. (2005). Coping with Alcohol and Drug Problems: The Experiences of Family Members in
Three Contrasting Cultures, London: Brunner-Routledge
How large is the problem?
It is estimated that there are approximately 15 million people
with drug use disorders globally and 76 million with alcohol
use disorders (Obot, 2005).
A cautious estimate of just one person seriously affected in
each case suggests a minimum of 91 million affected
family members
Most people would use a greater multiplier and produce a
higher figure
What is the extent of the problem?
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Drug treatment
population
General
population
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50,373 partners
55,012 parents
35,208 ‘other’
573,671 partners
610,970 parents
259,133 ‘other’
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Total = 140,593 Total =1,443,774
Key findings from UK DPC study
about adult family members of
drug misusers.
What about alcohol misuse?
Up to 1 million children are
affected by parental drug misuse
& up to 3.5 million by parental
alcohol misuse (Manning et al.,
2009).
It is estimated that the impact of
drug misuse on the family costs
the UK £1.8 billion but also
brings a resource saving to the
NHS of £747 million through the
care provided.
The impact of addiction on the
family: a global public health
problem
We have conducted research with family
members in:
 England, Mexico City, Australia (Aboriginal
communities) and Italy
► What we have been told suggests that the
impact of addiction problems on the family is
remarkably similar all over the world.
► Particular elements of this experience can differ
or be more prominent according to culture and
social context.
►
THE UNIQUE SET OF STRESSFUL
CIRCUMSTANCES FOR FAMILIES COPING
WITH ADDICTION
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Has the nature of severe stress, threat and abuse
Involves multiple sources of threat to self and family, including emotional,
social, financial, health and safety
Can have significant impact on children
Worry for that family member is a prominent feature
There are influences in the form of individual people and societal attitudes that
encourage the troubling behaviour
Attempting to cope creates difficult dilemmas, and there is no guidance on the
subject
Social support for the family is needed but tends to fail
Professionals who might help are often at best badly informed and at worst
critical
Symptoms of Ill Health
Control
Psych
P.Care
2
P.Care
1
Wives
Mexico
35
30
25
20
15
10
5
0
UK
Family Family members; psychiatric out-pts. and
community controls
members
Ray et al (2007)
Compared family members of people with substance misuse problems
with family members of similar persons without substance misuse.
Samples:
Family members n = 45,677 (male/female – 46/54%)
Comparison group n = 141,722 (male/female – 46/54%)
More likely to be diagnosed with medical conditions most commonly
depression and substance abuse
Ray et al (2007) The excess medical cost… Medical Care
Examples of affected family members from
some of our research studies
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A British Pakistani woman (husband with drug problem): their three
children, her family & her husband’s parents.
A Mexican father (son with drug problem): his wife and their three
children
A British Indian woman (husband with drug problem): young son, her
mother, her husband’s parents and an aunt.
An English sister (brother with drug problem): brother’s child,
husband, children, husband’s family & her mother.
A Mexican mother (daughter with alcohol problem) living in a large
household consisting of four generations including mother, brothers
and sisters and three children and their families
An Australian cousin living in a remote rural community (his cousin
has an alcohol problem): his wife and two children. Next door lives
problem drinking cousin and his family. Family member has family
obligations and two households share daily activities.
We know that family members have
two related needs:
To receive advice and support on
their own right
To be supportive of the relative’s
treatment and involved if useful
Family Interventions
Family Interventions: Three
Broad Categories
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interventions that work with family members to
promote the entry and engagement of drug and/or
alcohol users into treatment
the joint involvement of family members and the
relatives using drugs and/or alcohol in the treatment of
the user
interventions aimed to respond to the needs of family
members affected by drug and alcohol problems in
their own right
[Copello, Velleman and Templeton, 2005]
TREATMENTS INVOLVING FAMILY MEMBERS (FMs)
Working With FMs
to engage relation in treatment
►Family
intervention
►Community
reinforcement & family
training
Joint involvement of FM Responding to Needs of FM
and their relatives in treatment
►Conjoint
therapy
family group
►Behavioural
therapy
couples
in their own rights
►Concurrent
treatment
►Al-Anon
►Families
►Unilateral
therapy
Family
Anonymous
therapy
►Supportive
►Cooperative
counselling
►Pressure
►Family
group
to change
►Network
►Social
therapy
behaviour &
network therapy
stress
management counselling
►Parent
training
►5
coping skills
- step intervention
Copello, Templeton et al. (5-STEPS) – family
member focused
1. Listen non-judgementally
2. Provide information
3. Discuss ways of responding
4. Explore sources of support
3. Arrange further help if needed
What can we learn form the
most recent research
studies?
Copello, A., Templeton, L. and Velleman, R. (2006) Family
Intervention for drug and alcohol misuse: Is there a best
practice? Current Opinion in Psychiatry, 19, 271-276.
Some Conclusions
[Copello, Velleman and Templeton, 2005]
MORE SPECIFIC
► Some very good interventions available
► Engaging users is possible but also good outcomes
for Family Members (FM)
► Working with users and families leads to positive
substance related outcomes
► No measure of FM related outcomes
► FMs symptoms can improve even after relatively
brief interventions irrespective of substance
related outcomes
Is there enough evidence to
propose a best practice?
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Best practice is not only related to interventions. The
evidence strongly supports the need to assess partner
relationships when people enter treatment, a practice that
is not widespread within treatment services
There is long-standing evidence that the nature and quality
of spousal relationships has a significant impact on
treatment outcomes
The real challenge, however, is posed by the evidence that
shows very low levels of implementation of these evidencebased family approaches in routine practice
This problem of the lack of implementation of the
evidence-base into routine practice, however, is not
restricted to family approaches.
Is there enough evidence to
propose a best practice?
Because several approaches have potential, ‘best
practice’, in services should include:
► a) routine assessment of the strengths and needs
of substance misusers’ current familial and social
networks
► b) implementation of one or more of the range of
evidence-based approaches which impact either
on the substance user in their familial/social
context, or on the affected family members.
8.10.7 Clinical practice recommendations
8.10.7.1
Where the needs of families and carers of people who misuse drugs have
been identified, staff should:
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Offer guided self-help, typically consisting of a single session with the
provision of written material
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Provide information about, and facilitate contact with, support groups,
such as self-help groups specifically focused on addressing families’
and carers’ needs
Taken from Drug Misuse: Psychosocial Interventions: The NICE Guideline, published by The British
Psychological Society and The Royal College of Psychiatrists (2008) p.205
8.10.7 Clinical practice recommendations
8.10.7.2
Where the families of people who misuse drugs have not benefited, or are
not likely to benefit, from guided self-help and/or support groups and
continue to have significant problems, staff should consider offering
individual family meetings. These should:
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Provide information and education about drug misuse
Help to identify sources of stress related to drug misuse
Explore and promote effective coping behaviours
Normally consist of at least five weekly sessions
Taken from Drug Misuse: Psychosocial Interventions: The NICE Guideline, published by The British
Psychological Society and The Royal College of Psychiatrists (2008) p.205
What happens in
practice?
Practice
Some very good examples of
services for family members but
provision is patchy
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Implementation of evidence based
practice remains low
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Potential to improve availability
and response to families
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Addiction and the family: is it time for
services to take notice of the
evidence? (Copello and Orford, Addiction, 2002)
POTENTIAL HURDLES/BARRIERS
►Theoretical
►Practical
►Treatment
focus needs to be broadened
►Commissioners
and service providers
recognition of broader sets of outcomes
Implementation
► Implementation
is not the responsibility of service
deliverers alone. There is a clear role here for
national and regional policy makers /
commissioners of services, in recognising that the
evidence suggests a move away from
individualistic approaches towards ones more
rooted within people’s social context and social
networks. They, too, have a responsibility to
support and encourage services to shift from their
individualistic stance towards a more socially
inclusive provision [Copello, Templeton and
Velleman, 2006].
Policies and Guidelines
Drug Strategy 2008
NICE Guidelines 2008 &
NTA Guide 2008
So, where are we now?
► Some
evidence informing developments
► Need
a flexible approach that can be used
to respond to the range of needs
► Service
support
providers need models, training and
Despite the available evidence and
potential gain, shifting the
emphasis from individualised
treatment approaches to those
focused on the substance user’s
family and social environment
presents a number of significant
challenges
Concluding thoughts: a case of
global public health neglect?
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A significant public health problem.
The impact and cost of the care given by family members
is significant.
Alcohol and drug policies do not adequately address the
needs of family members or how they can be involved in
treatment.
Service delivery remains predominantly oriented towards
the focal alcohol or drug client, although there is evidence
of a wide range of interventions to support families, and
some evidence that more services are becoming available.
An effective response to the needs of family members
has the potential to significantly reduce harm and health
problems in this group
Thank you for listening…
Some selected useful references
Copello, A., Templeton, L., Velleman, R., Orford, J., Patel, A., Moore, L. and Godfrey, C. (2009). The
relative efficacy of two primary care brief interventions for family members affected by the addictive
problem of a close relative: a randomised trial, Addiction, 104, 49-58.
Copello, A., Templeton, L. and Velleman, R. (2006) Family Intervention for drug and alcohol misuse: Is
there a best practice? Current Opinion in Psychiatry, 19, 271-276. (Invited review)
Copello, A., Orford, J., Tober, G and Hodgson, R. (2009). Social Behaviour and Network Therapy for
Alcohol Problems. London: Brunner Routledge.
Copello, A., Velleman, R. and Templeton, L. (2005) Family interventions in the treatment of alcohol and
drug problems. Drug and Alcohol Review. 24, 4, 369-385.
Copello, A. and Orford, J. (2002) Addiction and the Family: Is it time for services to take notice of the
evidence? Addiction, 97, 1361-1363.
Copello, A., Orford, J., Velleman, R., Templeton, L. & Krishnan, M. (2000). Methods for reducing alcohol
and drug related family norm in non-specialist settings. Journal of Mental Health, 9, 329-343.
Copello, A., Templeton, L. and Powell, J. (2009) Adult family members and carers of dependent drug
users: Prevalence, social cost, resource savings and treatment responses. UK Drug Policy
Commission.
Orford, J., Natera, G., Copello, A., Atkinson, C., Tiburcio, M., Velleman, R., Crundall, I., Mora, J.,
Templeton, L.., & Walley, G. (2005) Coping with Alcohol and Drug problems: the Experiences Of
Family Members In three Contrasting Cultures. London; Taylor and Francis.