1. 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
Presented at: Recovery & Reintegration Event - 20th July 2010, Belfry, Cambridge

2. 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

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
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.

4. …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

5. 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]

6. What do we know from research?

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Family Interventions

17. 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]

18. 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

19. 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

20. 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, 20

21. 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

22. 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.

23. 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.

24. 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

25. 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

26. What happens in practice?

27. 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

28. 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

29. 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].

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

31. 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

32. 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

33. 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

34. Thank you for listening…

35. 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, 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., 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, Copello, A. and Orford, J. (2002) Addiction and the Family: Is it time for services to take notice of the evidence? Addiction, 97, 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, 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.