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 a.g.copello@bham.ac.uk 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 The University of Birmingham/Birmingham and Solihull Mental Health NHS Trust Substance Misuse Service Jim Orford Akan Ibanga Alex Copello 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

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]

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? 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. Drug treatment population General population 50,373 partners 55,012 parents 35,208 ‘other’ 573,671 partners 610,970 parents 259,133 ‘other’ Total = 140,593 Total =1,443,774 9

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. 10

THE UNIQUE SET OF STRESSFUL CIRCUMSTANCES FOR FAMILIES COPING WITH ADDICTION 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 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

Examples of affected family members from some of our research studies 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 presented these in UK DPC report – may or may not be a good idea for this presentation. Note, if we use that I have only used English data so we might want to give a couple of examples from Mexico, Australia etc. 14

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 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 relation 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

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. 20

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? 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 evidence-based 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: 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

What happens in practice?

Practice Some very good examples of services for family members but provision is patchy Implementation of evidence based practice 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

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 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

Concluding thoughts: a case of global public health neglect? 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 33

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.