1. 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
Presented at: Sixth Annual Drug & Alcohol Professionals Conference:
13th January, 2009
Royal Institute of British Architects, 66 Portland Place, London W1B 1AD

2. 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

3. 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.

4. 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]

5. RESEARCH
POLICY
PRACTICE

6. 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]

7. What do we know from research?

8. 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

9. 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

10. Family Interventions

11. 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]

12. 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

13. 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

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

15. 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

16. 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

17. 5 Step Intervention: Changes in symptoms and coping behaviour Copello, Templeton, Orford, Velleman et al., (2009) Addiction
Symptoms
Coping

19. What happens in practice?

20. 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

21. 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

22. 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

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

24. 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].

25. Policies and Guidelines Drug Strategy 2008 NICE Guidelines 2008 & NTA Guide 2008

26. 8.4.10 Clinical practice recommendation
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

27. 8.10.7 Clinical practice recommendations
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

28. 8.10.7 Clinical practice recommendations
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

29. 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

30. 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

31. 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

32. Thank you for listening…

33. 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, 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, (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, 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).