BROADENING THE DEBATE

David McPhillips

Deputy Manager CSMT

Msc Drug & Alcohol Policy Trinity 2012

Current PhD student- UL Psychology Department-. Focusing on EBT and retention of youth substance misusers

Topics• Rationale for supporting families

• Type of support

• Experience of CSMT

• Populist views- alcoholic family

• Treatment outcomes

Introduction• Both generic and specialist health and social services have

long recognised the difficulties experienced by family members of problem drinkers and drug users, but the provision of helping services for such family members has rarely been as systematic as it might be.

• Furthermore, some of the better-known models of service provision in this field have been based on controversial family systems ideas which assume that all family members are themselves dysfunctional or ‘codependent ‘ and as such in need of treatment- ‘detach with love’ (Butler 2012)

• New models of work in contrast to previous held beliefs including:• ‘5-Step Method: stress, strain, coping responses.• CRAFT – family member influences substance misuser to seek treatment.

• The attempt to make a bridge between two systems:• System one – substance treatment systems – primarily

focussed on individual adult patient health outcomes• System two – child care systems – primarily focussed on

parent/child dyad and social/health outcomes for children• Denial of mutual impact of systems • Lack of cohesive response

Hidden Harm (ACMD, 2003)– what actually was it?

Rationale for working with family members

• Alcohol and drug problems affect not only those using these substances but also family members of the substance user.

• There is a solid evidence base for the negative effects of

substance misuse in the family: especially with spouses

and parents (Copello et al 2005).• Very large number of studies demonstrate negative effects

on children while they are still young and in early adolescence (Velleman 2007).

• Substance misuse can impact negatively on a range of family systems and processes including: family rituals, roles within the family, family routines, communication.

• .

Continued

• Problems such as domestic and other types of violence, child abuse, individuals driving while intoxicated or disappearing for days on end are all typical types of behaviour that people have described as stressful and with which they have to cope

• Substance misuser’s often report that family members prompted treatment seeking

• Family members can influence substance misuser’s behaviour

Interventions• Several family-focused interventions have been

developed. They can be broadly grouped into three types:

• (1) working with family members to promote the entry and engagement of substance misusers into treatment;

• (2) joint involvement of family members and substance misusing relatives in the treatment of the latter; and

• (3)interventions responding to the needs of the family members in their own right.

Working with family members to promotethe engagement of substance misusers

into treatment• CRAFT an extension of the Community Reinforcement Approach

(CRA) method that aims to work with ‘concerned significant others’ (CSOs) to reinforce non-substance misusing behaviour through a positive reinforcement process.

• Family member can influence behavioural change in user• Substance misusers often report that family pressure impacted on

decision to seek treatment (Prochaska & Di Clemente)• Family members can be very knowledgeable about the misuser and

this information can be used to withdraw ‘rewards’ and influence behavioural change

• Removes pathologising of families (Alcoholic family-some way damaged)

• Empowers

Goals of CRAFT• Reduce loved one’s substance misuse• Engage loved one into treatment• Improve the functioning of the concerned person-

emotional, physical, relationships

5 Step Method- Helping children and family membersAn important principle of the model is that living with a

highly stressful experience such as the impact of an addiction problem in the family, may lead to psychological and physical symptoms of ill health in family members other than the substance user (Copello 2010)

In addition to the methods outlined earlier, this approach may benefit children by reducing the levels of stress they experience, and the provision of relevant information may help the child to understand concepts (such as ’tolerance,’ ’blackouts’ and ’withdrawal’) and the parent’s behaviour, helping to reduce self-blame and guilt about parental drinking (Emshoff 1999

The 5-Steps

1. Getting to know the family member and the problem – exploring stresses and strains

2. Providing relevant information

3. Exploring and discussing coping behaviors (research indicates 3 broad types of coping – Engaged, Tolerant and Withdrawal)

4. Exploring and enhancing social support (useful to draw a social network diagram)

5. Ending & exploring additional needs and further sources of help

Community Substance Misuse Team- www.csmt.ie• Early intervention service• Cover the Mid-West- Clare, Limerick City & County, North

Tipperary• Multi-disciplinary team- Staff have background in social

work, counselling, youth work, drug and alcohol policy, addiction studies.

• Seeks to provide an accessible, non judgmental service to parents and adolescents in the Mid-West region

• Tier 2- Education/Prevention service initially• Demand has steered service into Tier 3 with a treatment

focus

CSMT• High number of referrals from ‘problematic’ youth

substance misusers- social work, probation, family member, youth-services.

• Generally high levels of engagement from youths > 10 sessions and majority of guardians engage in the process- consent must be obtained to utilise service for U18’s

• Urban v’s rural – engagement levels, presenting issues vary, displacement into rural areas, isolation, tradition of service attendance v’s shame, guilt, lack of trust

CSMT• Utilises the Adolescent Community Reinforcement Approach

for youth substance misusers – EBT • ALL staff are accredited and one in house ACRA Trainer• ACRA consists of 14 sessions, CBT elements- FA,

Happiness scales, skills element- problem solving, communication, job counselling and also a family element 2-3 sessions focusing on:• Relationship happiness scale – care giver and young person• Communication• Problem solving• Developing empathy and support• Reducing conflict in the home• Clear boundaries• Improving parental capacity

• One to one work and group sessions• Phone and text support• Crisis support• Space to decide on approach to deal with youth- intimidation, drug

debts, cohesive response• Parenting support groups.• How?

• ACRA tools• CRAFT• 5 Step Method• Relaxation groups• Alternative therapies• Being available as a worker!• No judgement- approx. 80% of 15-16 year olds will consume alcohol, approx 20%

of 15-16 year old an illict drug- ESPAD study, • Normalisation of licit and illicit substance misuse

Services provided to families

CSMT- SFP• Responsible for delivery of Strengthening Families

Programmes in collaboration with the local FRC’s • SFP- 14 week skill based EBP • Strengthening families has been proving a successful

means of providing support and tools / skills to families in the Mid-West region over the past 5 years. In other areas research has shown the potential benefits of the programme in increasing the strengths of family relationships, parenting skills and youth social and life skills:

SFP Overview• Typical night:

• 30 minutes: Dinner families + facilitators• 1st Hour: Separate Teen Group & Parent Group• 2nd Hour: Families re-join & work in small groups• Home exercises for teens, parents, family• Debriefing session for facilitators.

• Key objectives of SFP:• To provide family skills training programme to reduce problem behaviours in young

people.• Improve parenting skills to ensure better positive role model behaviour from

parents. • Put training and support structure in place for vulnerable families. • To reduce risk factors for families.• Build resilience and support families to reduce risk factors.• To provide an outlet for families in the community experiencing stress and

disadvantage to build parenting, social & communication skills.•  •  

CSMT• Clare Youth Group- a support group for youths impacted

by parental substance misuse: Interagency approach with HSE, Bushypark, MWRDAF, Clare Youthservice

• Positive outcomes for participants- ‘a space to difficulties at home’

• Facilitators have youth work and counselling background• Programme focuses on improving coping skills in a group format• Hard to reach cohort makes it difficult to engage youths• Support provided post group

What has CSMT learned as of December 2014

• Engagement of youths is needed and ‘wanted’• ‘FEAR’ is driving ineffective responses• Treatment needs to focus on improving protective factors in young people

and building the capacity of families to respond effectively• Family members are often the ‘most impacted’ in terms of health and

wellbeing (5 step questionnaire) and as such need to be supported• ‘Relationship matters’- both with youths and parents• Communication & Trust enable successful outcomes• Generally referrals for youths impacted come from their parent(s) who are

in recovery and reflecting on their behaviour• Targeting those affected by a family member’s substance misuse is

challenging and time consuming• Youths respond to ‘interest’• Make a service accessible: local clinics in the areas – build on

relationships already in place•  

Urban v’s Rural CSMT • Service trust• Stigma• Guilt and shame• Service engagement• Lack of tradition of services in areas• Different presenting issues• Different thresholds from social workers and other

professionals who refer in?• Alternative activities• Isolation• Protective factors• Availability

Family as a protective factor: • Young single mother, 26• Son 2 years old when heroin addiction began- active

addiction for 4 years- then long term treatment in a mother and child treatment facility- Ashleigh house- Coolmine.

• No social work involvement. Grandparents highly supportive as were other family members.

• Child now 11- no knowledge or understanding that their were problems in the past, the impact had been greatly minimised due to? Question: Is this possible - Discuss• “The most positive thing is that my son didn’t have to grow up and be

exposed to all that shit. That I had my life back that I had initially and more, that I have my confidence back, do more things, go to college, getting to know yourself as a person and improving myself (Gina)” David McPhillips’ ‘Recovery from illicit substance misuse’ 2012

Continued• Child now 11- impact of addiction had been greatly minimised due

to?• Role of grandparents in maintaining rituals• Emotional support maintained• No conflict in front of child• No discussion around ‘addiction’ in front of child• Child not engaged in the process or used in a manipulative way to

alter behaviour• Consistency for the child• Language used- treatment was a ‘job’• Protective factors in place• Lack of conflict in the home, child was not exposed to conflict• Treatment model exposed to, the concept of ‘de-addiction’- ‘not

being sick for life’

Case: CSMT• Grandmother presented at the service concerned about her

daughters benzo use. 2 grandchildren in the home, 14 and 10. all living in small home as well as partner of grandmother. Grandmother was engaged in trying to prevent her daughter from using drugs. Grandmother would check the bags of her daughter with her grandson (10) trying to find evidence of drug use. Grandmother and daughter had numerous conflicts in front of the children, grandmother’s partner also lived in the house and was a positive role model for the children.• Grandson 14 engaged with the service- very angry, felt ‘embarrassed’ ,

confronted mother a number of times, used name calling to elicit change in his mother, very abusive towards his mother

• Daughter engaged with the service- would not acknowledge drug problem or affect on family

• Grandmother willing to engage in the service• What are the supports this family could benefit from?

The ‘Alcoholic Family’• Popular cultural approach to this issue based on American

ideas about addiction and recovery• Alcoholism is described a family disease, which means

that every member of the family is symptomatic or dysfunctional, and that all family communications and relationship systems are unhealthy

• The implication is that children of problem drinkers are inevitably damaged – emotionally and behaviorally – both in their childhood and perhaps in the long-term

• Such families are thought to need specialist ongoing counselling (Butler)

Dysfunctional Roles in ‘Alcoholic’ Families

• Alcoholic –stereotypically husband / father• Enabler / Codependent – usually wife/mother who is

emotionally martyred and super-responsible• Hero – often oldest child who is an overachiever with low

self-esteem• Scapegoat – delinquent, provocative child who incurs the

wrath of school systems and juvenile justice systems • Lost child – a child who remains unobtrusive and is ‘no

trouble’• Mascot - a child who uses humour compulsively to deal

with anxiety (Butler)

Critique of ‘Alcoholic Family’ Concept• This concept reflects a negative stereotypical view,

lacking empirical evidence to support it, and ignoring protective ‘mediators’ and individual resilience

• Parental drinking problems are, however, an important risk factor for the creation of children’s problems

• Outcomes vary enormously and problems are not unique to this type of dysfunctional family

• More specific stressors: 1) marital conflict between parents;2) inconsistent parenting & rule setting; 3) breakdown of ‘family rituals’

• Professionals should assess families carefully, rather than assuming that they are ‘alcoholic families’

Resilence• Despite the evidence of increased risks to children living

with problem drinkers, a large body of evidence suggests that most are remarkably well-adjusted (Sher 1991) or resilient (Velleman 1999)

• Resilience has been variously defined as “an interactive concept that is concerned with the combination of serious risk experiences and a relatively positive psychological outcome despite those experiences” (Rutter 2006)

Resilence

Velleman 2007 identified a range of factors that provide evidence of resilience in children of substance misusers, including: • deliberate planning by the child that their adult life will be different;• high self-esteem and confidence; • self-efficacy; • an ability to deal with change; • skills and values that lead to good use of personal ability; • a good range of problem-solving skills; • feeling that there are choices; • feeling in control of their own life; and previous experience of

success and achievement.

Importance of Family Rituals • Concept reflecting how children thrive on security, stability

and predictability as a feature of their lives• Depending on how the non-drinking parent copes, the

fabric of family life can be largely preserved against the depredations of the other parent’s alcohol problem

• The rituals in question are: 1) daily (e.g. mealtimes, bath & bedtime games, school, creche etc.; 2) annual (e.g birthdays, Christmas, summer holidays); 3) lifetime (e.g. First Communion, Confirmation, family weddings)

• Where rituals are preserved risk is reduced – regardless of severity of parental alcohol dependence

CSO- Concerned significant other

Research suggests that having a supportive adult or confidant, either within the immediate family (if only one parent has a drink problem) or in the extended family and beyond, can help to build resilience, encouraging the development of functional coping behaviours.

The social support provided by these significant adults (e.g. relatives, teachers) can help to alleviate the risk of developing maladaptive coping strategies (such as drug and alcohol use) and the onset of emotional or mental health problems.

Summary • Family members play a vital role in substance misuser’s

accessing treatment• Family members can be heavily effected by a substance misuse • Supporting family members improves overall treatment

outcomes • Children living with parents with alcohol problems are at risk

rather than inevitably doomed• Professionals should assess carefully for moderators as well as

stressors• Family ritual preservation and a reduction in marital disharmony

are protective for children, and non-drinking parents can be helped to improve their coping strategies (e.g. through use of Stress-Strain-Coping-Support , 5-Step model)

Policy Implications• Families are demonstrably important in this area, yet little

emphasis is given to them. • Family involvement in interventions, either as part of

successful treatments for problem misusers or as needing help in their own right needs to be facilitated by services

• There are major issues of child protection raised by the large numbers who reside with substance misusing parents

• Child protection issues with youth substance misusers?• Does treatment work? The traditional residential treatment

systems are evidenced to have minimal long term impact yet popular beliefs tells us ‘they need treatment’

• Youths do want to engage in services- current PhD study on youth retention and engagement

Reading List• Wegscheider-Cruse, S. (1989). Another Chance: Hope and Health for the Alcoholic

Family. (Palo Alto, California: Science and Behaviour Books). • Geringer Woititz, J. (1990). Adult Children of Alcoholics (revised edition). (Deerfield

Beach,Florida: Health Communications Inc.).• Anderson, S. (1994). ‘A Critical Analysis of the Concept of Codepency’, Social

Work, 39, 677-685.• Wolin, S.J. and Wolin,S. (1994). The Resilient Self: how survivors of troubled

families rise above adversity. (New York: Villard Books).• Velleman, R. and Orford, J. (1999). Risk and Resilience: Adults Who Were the

Children of Problem Drinkers. (Reading: Harwood).• Velleman, R., Copello, A. and Maslin, J. (eds) (1998). Living with Drink: women

who live with problem drinkers. (London: Longman).• Orford, J., Natera, G., Copello, A. et al. (2005). Coping With Alcohol and Drug

Problems: The experiences of family members in three contrasting cultures. (London: Routledge).

• The 5-Step Method: A Research-Based Programme of Work to Help Family Members Affected by a Relative’s Alcohol or Drug Misuse. (Drugs: education, prevention and policy, vol. 17, supplement 1, 2010)