Families, addiction and recovery Louise Martin and Alex Copello Skills Consortium conference, London, 14th February 2012

Individual vs. social view of addictions AC

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) AC

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 clients’ using behaviour We need to consider the whole system of the family, not just the individual when thinking Recovery. LM

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 LM

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 AC

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 AC 7

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 AC

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 AC

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 AC

Policy LM

NTA (2008) “Supporting and Involving Carers” Involve family in treatment where appropriate Involve family in service planning Routinely ask about family Offer carers assessments Develop support plan if needed Help family think about how to cope with substance use LM

Drug Strategy 2010 “Evidence shows that treatment is more likely to be effective, and recovery to be sustained, where families, partners and carers are closely involved. We will encourage local areas to promote a whole family approach to the delivery of recovery services and to consider the provision of support services for families and carers in their own right” LM

NICE (2007) Drug Misuse: Psychosocial Interventions Routinely ask about family, and the impact of substance use on family Involve families in assessment and treatment plan (with consent of client) Offer carers assessment Provide written information about impact of drug misuse on families Offer guided self help where needed Provide information about support groups 5 sessions based on Copello’s model Behavioural Couples Therapy LM

What happens in practice?

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 AC

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 AC

Family Interventions

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] AC

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 M-PACT AC

The stress-strain-coping-support model Relative’s substance problem Stress on family member Social support Ways of coping AC Family member strain

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 AC

A little support can have wide positive consequences Key message: A little support can have wide positive consequences AC

What do you do in your services? LM

What can you do? Find out what’s available in your area and decide what you can offer as a service Identify families ‘champions’ Produce an information leaflet for families and carers Let administrator/ receptionist know what you offer Add a question about family members to your assessment form Add ‘family’ to your regular team meeting agendas Organise a ‘friends and family day’ at your service Organise 5-step training for staff Get systems in place for recording contacts, safeguarding issues etc LM

Potential Obstacles Not allocating sufficient resources Absence of managerial buy-in Expecting this to be done on top of normal caseloads Seeing it as a ‘luxury’ rather than core Lack of systems for recording work Responsibility resting with one person LM