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Family Interventions & Evidence Based
Approach for Helping Families
Prof Alex CopelloProf Alex CopelloConsultant Clinical Psychologist Consultant Clinical Psychologist
Addiction Services Addiction Services Birmingham and Solihull Mental Health Foundation NHS Trust Birmingham and Solihull Mental Health Foundation NHS Trust
&&Professor of Addiction ResearchProfessor of Addiction ResearchThe University of BirminghamThe University of Birmingham
Presented at:Presented at: Recovery & Reintegration Event - 20th Recovery & Reintegration Event - 20th July 2010, Belfry, CambridgeJuly 2010, Belfry, Cambridge
Addiction and the FamilyAddiction and the FamilyPlanPlan
►AcknowledgementsAcknowledgements►Why families matterWhy families matter► Impact of addiction problems Impact of addiction problems
on familieson families►What do we know from What do we know from
research on interventions?research on interventions?►What happens in practiceWhat happens in practice►Some conclusionsSome conclusions
ADDICTION AND THE FAMILY (ADF) ADDICTION AND THE FAMILY (ADF) GROUPGROUP
► The University of Birmingham/Birmingham and Solihull Mental The University of Birmingham/Birmingham and Solihull Mental Health NHS Trust Substance Misuse ServiceHealth NHS Trust Substance Misuse Service
Jim OrfordJim OrfordAkan IbangaAkan IbangaAlex CopelloAlex Copello
► The University of Bath Mental Health R&D Unit/Avon & The University of Bath Mental Health R&D Unit/Avon & Wiltshire Mental Health Partnership NHS TrustWiltshire Mental Health Partnership NHS Trust
Lorna TempletonLorna TempletonRichard VellemanRichard Velleman
…….and numerous other colleagues who have been part of this group over .and numerous other colleagues who have been part of this group over the years both in the UK and other countries.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
During the past 3 decades, there has been During the past 3 decades, there has been increased recognition from researchers of the increased recognition from researchers of the key role that families can play in substance key role that families can play in substance
misuse treatment, in terms of:misuse treatment, in terms of:
► preventing and/or influencing the course of the preventing and/or influencing the course of the substance misuse problem substance misuse problem
► improving substance-related outcomes for the improving substance-related outcomes for the user user
► helping to reduce the negative effects of helping to reduce the negative effects of substance misuse problems on other family substance misuse problems on other family members. members.
[Copello, Templeton and Velleman, 2006][Copello, Templeton and Velleman, 2006]
What do we know from What do we know from research?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?
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.
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.
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 HealthSymptoms of Ill Health
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Family members; psychiatric out-pts. and
community controlsFamily members
Ray et al (2007)Ray et al (2007)
Compared family members of people with substance misuse Compared family members of people with substance misuse problems with family members of similar persons without problems with family members of similar persons without substance misuse.substance misuse.
Samples:Samples:Family members Family members n = 45,677n = 45,677 (male/female – 46/54%) (male/female – 46/54%)Comparison group Comparison group n = 141,722n = 141,722 (male/female – 46/54%) (male/female – 46/54%)
More likely to be diagnosed with medical conditions most More likely to be diagnosed with medical conditions most commonly commonly depression and substance abusedepression and substance abuse
Ray et al (2007) The excess medical cost… Ray et al (2007) The excess medical cost… Medical CareMedical 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.
To receive advice and support To receive advice and support on their own righton their own right
To be supportive of the To be supportive of the relative’s treatment and relative’s treatment and
involved if usefulinvolved if useful
We know that family members We know that family members have two related needs:have two related needs:
Family Family InterventionsInterventions
Family Interventions: Three Family Interventions: Three Broad CategoriesBroad Categories
► interventions that interventions that work with family memberswork with family members to to promote the entry and engagement of drug and/or promote the entry and engagement of drug and/or alcohol users into treatment alcohol users into treatment
► the the joint involvement of family membersjoint involvement of family members and the and the relatives using drugs and/or alcohol in the treatment of relatives using drugs and/or alcohol in the treatment of the userthe user
► interventions aimed to interventions aimed to respond to the needs of family respond to the needs of family membersmembers affected by drug and alcohol problems in affected by drug and alcohol problems in their own righttheir own right
[Copello, Velleman and Templeton, 2005][Copello, Velleman and Templeton, 2005]
►Concurrent group Concurrent group treatmenttreatment
►Al-AnonAl-Anon
►Families AnonymousFamilies Anonymous
►Supportive stress Supportive stress management management counsellingcounselling
►Parent coping skills Parent coping skills trainingtraining
►5 - step intervention5 - step intervention
Working With FMs to engage relation in treatment
Joint involvement of FMand their relatives in treatment
Responding to Needs of FMin their own rights
►Family interventionFamily intervention
►Community Community reinforcement & reinforcement & family trainingfamily training
►Unilateral Family Unilateral Family therapytherapy
►Cooperative Cooperative counsellingcounselling
►Pressure to changePressure to change
►Conjoint family Conjoint family group therapygroup therapy
►Behavioural couples Behavioural couples therapytherapy
►Family therapyFamily therapy
►Network therapyNetwork therapy
►Social behaviour & Social behaviour & network therapynetwork therapy
TREATMENTS INVOLVING FAMILY MEMBERS (FMs)TREATMENTS INVOLVING FAMILY MEMBERS (FMs)
Copello, Templeton et al. (5-STEPS) – Copello, Templeton et al. (5-STEPS) – family member focusedfamily member focused
1. Listen non-judgementally1. Listen non-judgementally
2. Provide information2. Provide information
3. Discuss ways of 3. Discuss ways of respondingresponding
4. Explore sources of support4. Explore sources of support
3. Arrange further help if 3. Arrange further help if neededneeded
Copello, A.,Copello, A., Templeton, L. and Velleman, R. (2006) Templeton, L. and Velleman, R. (2006) Family Intervention for drug and alcohol misuse: Is Family Intervention for drug and alcohol misuse: Is
there a best practice? there a best practice? Current Opinion in Psychiatry, Current Opinion in Psychiatry, 19, 271-276.19, 271-276.
What can we learn form What can we learn form the most recent research the most recent research
studies?studies?
Some ConclusionsSome Conclusions[Copello, Velleman and Templeton, 2005][Copello, Velleman and Templeton, 2005]
MORE SPECIFICMORE SPECIFIC► Some very good interventions availableSome very good interventions available► Engaging users is possible but also good Engaging users is possible but also good
outcomes for Family Members (FM)outcomes for Family Members (FM)► Working with users and families leads to Working with users and families leads to
positive substance related outcomespositive substance related outcomes► No measure of FM related outcomesNo measure of FM related outcomes► FMs symptoms can improve even after FMs symptoms can improve even after
relatively brief interventions irrespective of relatively brief interventions irrespective of substance related outcomessubstance 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 recommendations8.10.7 Clinical practice recommendations
8.10.7.1 8.10.7.1 Where the needs of families and carers of people who misuse Where the needs of families and carers of people who misuse
drugs have been identified, staff should:drugs have been identified, staff should:
► Offer guided self-help, typically consisting of a single session Offer guided self-help, typically consisting of a single session with the provision of written materialwith the provision of written material
► Provide information about, and facilitate contact with, support Provide information about, and facilitate contact with, support groups, such as self-help groups specifically focused on groups, such as self-help groups specifically focused on addressing families’ and carers’ needsaddressing 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 recommendations8.10.7 Clinical practice recommendations
8.10.7.28.10.7.2
Where the families of people who misuse drugs have not Where the families of people who misuse drugs have not benefited, or are not likely to benefit, from guided self-help benefited, or are not likely to benefit, from guided self-help and/or support groups and continue to have significant and/or support groups and continue to have significant problems, staff should consider offering individual family problems, staff should consider offering individual family meetings. These should:meetings. These should:
► Provide information and education about drug misuseProvide information and education about drug misuse► Help to identify sources of stress related to drug misuseHelp to identify sources of stress related to drug misuse► Explore and promote effective coping behavioursExplore and promote effective coping behaviours► Normally consist of at least five weekly sessionsNormally 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 What happens in practice?practice?
PracticePractice► Some very good examples of Some very good examples of services for family members but services for family members but provision is patchyprovision is patchy
► Implementation of evidence Implementation of evidence based practice remains lowbased practice remains low
► Potential to improve Potential to improve availability and response to availability and response to familiesfamilies
Addiction and the family: is it time Addiction and the family: is it time for services to take notice of the for services to take notice of the
evidence? evidence? (Copello and Orford, Addiction, 2002)(Copello and Orford, Addiction, 2002)
POTENTIAL HURDLES/BARRIERSPOTENTIAL HURDLES/BARRIERS
►TheoreticalTheoretical
►PracticalPractical
►Treatment focus needs to be broadenedTreatment focus needs to be broadened
►Commissioners and service providers Commissioners and service providers recognition of broader sets of outcomesrecognition of broader sets of outcomes
ImplementationImplementation
► Implementation is not the responsibility of Implementation is not the responsibility of service deliverers alone. There is a clear service deliverers alone. There is a clear role here for national and regional policy role here for national and regional policy makers / commissioners of services, in makers / commissioners of services, in recognising that the evidence suggests a recognising that the evidence suggests a move away from individualistic approaches move away from individualistic approaches towards ones more rooted within people’s towards ones more rooted within people’s social context and social networks. They, social context and social networks. They, too, have a responsibility to support and too, have a responsibility to support and encourage services to shift from their encourage services to shift from their individualistic stance towards a more individualistic stance towards a more socially inclusive provision [Copello, socially inclusive provision [Copello, Templeton and Velleman, 2006]. Templeton and Velleman, 2006].
Policies and GuidelinesPolicies and Guidelines
Drug Strategy 2008Drug Strategy 2008NICE Guidelines 2008 &NICE Guidelines 2008 &
NTA Guide 2008NTA Guide 2008
So, where are we now?So, where are we now?
► Some evidence informing developmentsSome evidence informing developments
► Need a flexible approach that can be usedNeed a flexible approach that can be used to respond to the range of needsto respond to the range of needs
► Service providers need models, training and Service providers need models, training and supportsupport
Despite the available Despite the available evidence and potential gain, evidence and potential gain, shifting the emphasis from shifting the emphasis from individualised treatment individualised treatment approaches to those focused approaches to those focused on the substance user’s family on the substance user’s family and social environment and social environment presents a number of presents a number of significant challengessignificant 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
Thank you for Thank you for listening…listening…
Some selected useful referencesSome selected useful referencesCopello, A., Templeton, L., Velleman, R., Orford, J., Patel, A., Moore, L. and Godfrey, C. 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 (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, affected by the addictive problem of a close relative: a randomised trial, AddictionAddiction, 104, , 104, 49-58.49-58.
Copello, A.,Copello, A., Templeton, L. and Velleman, R. (2006) Family Intervention for drug and alcohol Templeton, L. and Velleman, R. (2006) Family Intervention for drug and alcohol misuse: Is there a best practice? misuse: Is there a best practice? Current Opinion in Psychiatry, Current Opinion in Psychiatry, 19, 271-276.19, 271-276. (Invited (Invited review)review)
Copello, A.,Copello, A., Orford, J., Tober, G and Hodgson, R. (2009). Orford, J., Tober, G and Hodgson, R. (2009). Social Behaviour and Network Social Behaviour and Network Therapy for Alcohol ProblemsTherapy for Alcohol Problems. London: Brunner Routledge.. London: Brunner Routledge.
Copello, A., Velleman, R. and Templeton, L. (2005) Family interventions in the treatment of Copello, A., Velleman, R. and Templeton, L. (2005) Family interventions in the treatment of
alcohol and drug problems. alcohol and drug problems. Drug and Alcohol ReviewDrug and Alcohol Review. 24, 4, 369-385. . 24, 4, 369-385.
Copello, A. and Orford, J. (2002) Addiction and the Family: Is it time for services to take Copello, A. and Orford, J. (2002) Addiction and the Family: Is it time for services to take notice of the evidence? notice of the evidence? AddictionAddiction, 97, 1361-1363., 97, 1361-1363.
Copello, A., Orford, J., Velleman, R., Templeton, L. & Krishnan, M. (2000). Methods for Copello, A., Orford, J., Velleman, R., Templeton, L. & Krishnan, M. (2000). Methods for reducing alcohol and drug related family norm in non-specialist settings. reducing alcohol and drug related family norm in non-specialist settings. Journal of Journal of Mental HealthMental Health, 9, 329-343., 9, 329-343.
Copello, A., Templeton, L. and Powell, J. (2009) Adult family members and carers of Copello, A., Templeton, L. and Powell, J. (2009) Adult family members and carers of dependent drug users: Prevalence, social cost, resource savings and treatment dependent drug users: Prevalence, social cost, resource savings and treatment responses. UK Drug Policy Commission.responses. UK Drug Policy Commission.
Orford, J., Natera, G., Copello, A., Atkinson, C., Tiburcio, M., Velleman, R., Crundall, I., Orford, J., Natera, G., Copello, A., Atkinson, C., Tiburcio, M., Velleman, R., Crundall, I., Mora, J., Templeton, L.., & Walley, G. (2005) Mora, J., Templeton, L.., & Walley, G. (2005) Coping withCoping with Alcohol and Drug problems: Alcohol and Drug problems: the Experiences Of Family Members In three Contrasting Culturesthe Experiences Of Family Members In three Contrasting Cultures. London; Taylor and. London; Taylor and Francis.Francis.
