Families and addiction: Families and addiction: Stress, symptoms and coping Stress, symptoms and coping

responsesresponses

Professor Alex CopelloBirmingham and Solihull Mental Health

Foundation Trust andUniversity of Birmingham, UK

Families First – DDN, Adfam Conference Birmingham, Holiday Inn, 15th November 2012

…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

Individual vs. social view of addictions

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

(Copello, 2006)

A narrow individual focus on treatment and help fails to consider some well

proven facts:• That living with a significant alcohol or drug problem is a

highly stressful experience

• That the stress experienced leads to physical and psychological symptoms for family members

• That family members use generic and primary care services to seek help

• That family members provide significant care (e.g. UKDPC)• That family members can improve outcomes for the

substance user

BARRIERS...

to recognition and

to accessing formal and informal support

Why work with families?1. ‘Carer burden’ is extremely high and families need support in

their own right

• Costs are financial, social, psychological, physical and relational

• Reciprocity of well-being• Families indirectly influence relatives’ using behaviour• We need to consider the whole system of the family, not just

the individual when thinking Recovery.

Why work with families?

2. Improved client treatment outcomes

• Increases client entry into treatment• Improves engagement and retention of client in

treatment• Improves substance use outcomes for clients• Reduces relapse• Families play crucial role in facilitating recovery

The four most important people: how were they related to the drinkers?This graph shows how the participants were related to their four most important people. Frequencies of relationship type are shown for the 1st, 2nd, 3rd and 4th most important people to the drinker.

The majority of people entering alcohol treatment named their partner as the most important person, although family members were also a popular choice. Very few drinkers named their partner as least important person of the four. Members of close family were predominantly named as second or third most important, and friends were commonly named as third or fourth.

0

100

200

300

400

500

1 2 3 4

important person no.

fre

qu

en

cy s ignificant other

family

friend

other

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?

Drug treatment population

General population

50,373 partners55,012 parents35,208 ‘other’

573,671 partners610,970 parents259,133 ‘other’

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.

An International Picture

• We have spoken directly to family members in:– England– Mexico City– Australia (Aboriginal communities)– Italy

• What we have been told suggests that the impact of substance misuse on the family is remarkably similar all over the world.

• Yet, particular elements of this experience can differ or be more prominent according to culture and social context.

• This experience seems to be similar to people who live with other traumas.

Main Modifiers of the Core Family Member Experience

THE COREEXPERIENCE

Relationshipto misusing

relative

Culture: individual, familial

orcommunal

Licit or illicit: traditional or

recently introduced

Substances use pattern

Traditional vsModern family

roles

Is modifiedby

FM female or male

Family Material circumstances

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

21

05

101520253035

UK

Mex

ico

Wiv

es

P.Ca

re

P.Ca

re

Psyc

h

Cont

rol

Family members; psychiatric out-pts. and

community controlsFamily 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 other psychological problems

Ray et al (2007) The excess medical cost… Medical Care

Three Common ways of

responding

‘Putting up with it’

‘Standing up to it’

‘Withdrawing/Independence’

What happens in practice?

Practice

► Some very good examples of services for family members but provision is patchy

► Implementation of evidence based practice is low

► Potential to improve availability and response to families

To receive advice and support on their own right

To be supportive of the relative’s treatment and involved if useful

We know that family members have two related needs:

“Being there”“Give advice”

“Being a strength”“Day to day”

“Continuity of support”“Your time”

“Understanding”“Challenges”

5-Step Method

• 1 – Listen, reassure and explore concerns• 2 - Give relevant targeted information (eg

substances, treatment, support)• 3 - Explore coping responses – ‘engaged’,

‘tolerant’, ‘withdrawn’• 4 – Discuss social support – map• 5 – Discuss further support needs

TRANSFORMATIONS DESCRIBED BY FAMILY MEMBERS RECEIVING 5-STEPS IN PRIMARY CARE

• Increased focus on own life and needs (gaining independence)

• Increased assertiveness over the misuse (resisting and being assertive)

• Taking a calmer approach towards the misusing relative (reduced emotional confronting)

• Increased awareness of the relative’s misuse problem and its effects on family members (cognitive change)

Key message:

A little support can have wide positive consequences

But most important:

Seeing family members as partners in the challenging task of helping people change addictive behaviours

UKDPC research on adult family /carers

Phase 2: 2011-12Aims•To describe the extent and nature of support provision for adult family members / carers of people experiencing drug problems to highlight gaps and good practice to help improve provision.

Components:•Review of policy & guidance in the UK•Web survey of service providers in the UK•In-depth study: 20 DAT areas in England & 8 ADPs in Scotland

Research team: Alex Copello, Lorna Templeton, Gagandeep Chohan & Trevor McCarthy

2

Policy review findings[Note: Unpublished – please do not quote without permission]

• Increased level of recognition of families in policy & guidance

BUT

• ‘Families’ generally = children of substance-using parents

• Little consideration of sub-groups of adult family members & their varying needs

• More focus on involvement in treatment than help in own right

• Lack of detail on what needs to be provided

• Little consideration of monitoring quality or extent of provision

• Need more recognition in strategies in related policy areas (eg criminal justice; DV).

3

Web survey findings[Note: Unpublished – please do not quote without permission]

Characteristics of services•253 services from across the UK (70% non-statutory)

145 - England 71 - Scotland 22 - N Ireland 14 - Wales

•Type of service58% = Part of service for substance misusers24% = Service solely for adult family members10% = Part of generic carers service 8% = Other

•Who worked with89% = Drugs and alcohol59% = Families alongside drug users11% = Drugs only 41% = Adult family member only

3

Web survey findings[Note: Unpublished – please do not quote without permission]

Support to family members on their own

3

Counselling 48%Bereavement 29% Co-dependency-based 22%

5-step method 9%12-step support 7%

CRAFT 1%PACT (1)

Family therapy (1)

Web survey findings[Note: Unpublished – please do not quote without permission]

Support for family members and drug users together

3

Areas for action

• Improve needs assessment– different groups; – different needs; and– basic prevalence.

• Develop targets and outcome assessment– to enhance provision; and – demonstrate value and build evidence base.

• Promote the evidence– for what is needed; and – what works.

• Workforce development - specialist and generic.

3

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 are increasingly recognising 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…