Why families matter and implications for treatment Prof Alex Copello Consultant Clinical Psychologist Addiction Services Birmingham and Solihull Mental Health Foundation Trust & Professor of Addiction Research The University of Birmingham a.g.copello@bham.ac.uk Presented at: Sixth Annual Drug & Alcohol Professionals Conference: 13th January, 2009 Royal Institute of British Architects, 66 Portland Place, London W1B 1AD

Addiction and the Family Plan Acknowledgements Why families matter What do we know from research? Implications for treatment So, where are we now? Some conclusions

ADDICTION AND THE FAMILY (ADF) GROUP The University of Birmingham/Birmingham and Solihull Mental Health NHS Trust Substance Misuse Service Jim Orford Akan Ibanga Majid Mahmood Sherillyn McNeil Alex Copello The University of Bath Mental Health R&D Unit/Avon & Wiltshire Mental Health Partnership NHS Trust Lorna Templeton Richard Velleman Rhea Ashmore and other colleagues who have been part of this group over the years.

improving substance-related outcomes for the user 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]

RESEARCH POLICY PRACTICE

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 and Copello et al., 2006]

What do we know from research?

Symptoms of Ill Health Family members Family members; psychiatric out-pts. and community controls 2 1 5 10 15 20 25 30 35 UK Mexico Wives P.Care Psych Control

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

Family Interventions

Family Interventions: Three Broad Categories 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) Joint involvement of FM Working With FMs to engage relative in treatment Joint involvement of FM and their relatives in treatment Responding to Needs of FM in their own rights Concurrent group treatment Al-Anon Families Anonymous Supportive stress management counselling Parent coping skills training 5 - step intervention Family ‘intervention’ Community reinforcement & family training Unilateral Family therapy Cooperative counselling Pressure to change Conjoint family group therapy Behavioural couples therapy Family therapy Network therapy Social behaviour & network therapy

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

Two examples of interventions Behavioural Couples Therapy (BCT) 5 – Step Intervention

IDEAS BEHIND BCT To eliminate abusive drinking and drug use To engage the family’s support for the patient’s efforts to change To change couple and family interaction patterns Stable relationship Stable abstinence

Copello, Templeton, Orford, Velleman et al Copello, Templeton, Orford, Velleman 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

5 Step Intervention: Changes in symptoms and coping behaviour Copello, Templeton, Orford, Velleman et al., (2009) Addiction Symptoms Coping

www.alcoholdrugsandfamilies.nhs.uk

What happens in practice?

Practice Some very good examples of services for family members but provision is patchy Implementation of evidence based practice is remains low Potential to improve availability and response to families

POTENTIAL HURDLES/BARRIERS 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

FAILURE TO INCLUDE FAMILY AND NETWORK Theoretical failure Individual Models Critical, pathologising models Ambiguous models Partial models Practical failure To minimise harm to affected family & others To enlist family and network support for change

FAILURE TO INCLUDE FAMILY AND NETWORK Commissioners and service providers recognition of broader sets of outcomes User focused Treatments & Outcomes Family related 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

8.4.10 Clinical practice recommendation 8.4.10.6 Behavioural couples therapy should be considered for people who are in close contact with a non-drug-misusing partner and who present for treatment of stimulant or opioid misuse (including those who continue to use illicit drugs while receiving opioid maintenance treatment or after completing opioid detoxification. The intervention should: Focus on the service user’s drug misuse Consist of at least 12 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.179

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: Offer guided self-help, typically consisting of a single session with the provision of written material 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: 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

NTA Guide for commissioners and providers 1.1. Key messages Providing services to meet the needs of families and carers leads to improvements for families, carers, children and drug misusers Areas without provision, or with limited provision, can benefit from developing or expanding services for families and carers Developing a family-friendly focus will assist providers to achieve the best outcomes for users and carers Involving families and carers can improve engagement, retention and outcomes for drug users in treatment Involving families and carers in the planning and commissioning of services improves the effectiveness of services and the drug treatments system Taken from Supporting and Involving Carers: A guide for commissioners and providers published by the National Treatment Agency 2008, p.7

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 providers need models, training and support

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

Thank you for listening…

Some selected useful references 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., 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. and Orford, J. (2002) Addiction and the Family: Is it time for services to take notice of the evidence? Addiction, 97, 1361-1363. 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. Velleman, R., Arcidiacono, C., Procenteses, F. and Copello, A. (2007). A 5-Step intervention to help family members in Italy who live with substance misusers, Journal of Mental Health (in press).