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Richard McVey & Claire Hampson

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1 Richard McVey & Claire Hampson
Increasing family-focused practice across an Organisation: Helping services become more family-focused Richard McVey & Claire Hampson ALEX

2 Introduction 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 et al., 2005) E.g. about 4 million people in the UK suffering as a result of problem alcohol user in their family (Copello, et al., 2000) important to develop strategies to meet their needs Growing research evidence to support the view that families and social networks can be influential when involved in treatment On the whole, routine addiction services remains focused on the individual drinker or drug user (Copello & Orford, 2002) ALEX Talk about how this research fits within this symposium and the shared recognition of the importance of developing strategies to help affected FMs.

3 Background Project part of a long programme of work aiming to understand the impact of alcohol and drug problems on the family and develop strategies in addiction practice to help reduce family strain Earlier work focused on: understanding the impact of alcohol and drug use on family members (FMs)(Orford et al., 1998a) natural family ways of coping (Orford et al., 1998b) development and testing evidence-based family-focused intervention in primary care (Copello, et al., 2000) and specialist teams (Orford et al., 2009) ALEX Recognising the need to overcome the state of neglect of the needs of concerned and affected family members related to substance misuse, Aquarius collaborated with the University of Birmingham on a programme of work designed to promote a whole organisation shift towards greater involvement of family members. Phase one of this programme of work entitled the ‘Involving Family Members (IFM) action research project’ took place between 2002 – 2004 and had provided one service within Aquarius (North CAT) with an opportunity to receive two-years of family-focused training and on-going supervision. Results from the IFM project revealed that family work had become successfully embedded in the team’s orientation, which now put concerned and affected members much nearer to the centre of their working ideology. The results also identified the need for the whole organisation to develop the support offered to family members and to increase all staff’s skills to be able to work effectively with family members and affected others.

4 Aims Whole Organisation approach
Provided a non-statutory addiction treatment Organisation an opportunity to receive training and on-going supervision in two family-oriented interventions: The ‘5-Step approach’ Social Behaviour and Network Therapy (SBNT) To promote a shift towards family-focused practice and to further advance implementation of family work into routine addiction services Allowed comparisons between teams at different time periods in order to evaluate the impact on the implementation of family-focused practice ALEX In 2008, Aquarius successfully acquired funding for this research study – the ‘Involving Family Members across the Organisation’ project, to train and supervise the remaining services within the organisation over a three year period. This was a significant philosophical shift for the organisation to now promote family work by all team members, to ensure all processes became more family-oriented. The primary research hypothesis was that the IFMO project would positively influence the adoption of family-focused practice across Aquarius. The aims of the study were, therefore: To develop an understanding of participating staff’s attitudes and views toward family-focused practice before, during and after the project. To monitor the implementation levels of family-focused practice across the organisation at key time-points during the three years. To explore any contextual factors that affected the project, and the way the project effects varied across the six teams.

5 Methods Mixed-methods quasi-experiment integrating action research
Made up of 2 phases over a 3-year period Phase one = pilot study: trained 2 teams (n=19) Phase two = random assignment to training 2 teams received immediate training (n=24) 2 teams received delayed training (n=19) (+1 team previously trained in IFM study) The Involving Family Members across the Organisation (IFMO) training and supervision package Two-day initial training event Eight monthly follow-up consultancy meetings One-day follow-up training event ALEX A two-phase quasi-experiment integrating action research was conducted between October 2008 and May The training and supervision package was sequentially rolled-out to the six teams over three years. Two teams were chosen by Aquarius to participate in the pilot phase. Phase two then employed a RCT whereby two teams were randomly chosen to receive ‘immediate’ training, whilst the remaining two teams’ training was ‘delayed.’ Design offered a number of opportunities for evaluation, allowing comparisons of the effects of the training package with baseline data. The study involved all Managers, Practitioners, Support and Admin staff from six Aquarius services (Solihull, South CAT, Northampton, Sandwell, Dudley and Wolverhampton). A total of 103 professionals participated in the study. All participants gave informed consent for their participation. All data provided remained confidential and anonymous. All participating staff received a 9-month package of family-focused training and support, delivered by the research team (Richard McVey, Alex Copello and Claire Hampson). The initial training event was organised around demonstrations and active skills-practice activities. Staff received author-developed manuals and hand-outs related to the two family-interventions. Skill building around family-focused practice was a clear goal of the training, but with an emphasis on developing the professionals’ understanding of the need to implement family-focused work within their service. Following the initial training event, eight 90-minute monthly supervision meetings with the research team were arranged with each team at their team base. These meetings offered on-going supervision by providing an opportunity each month to raise any issues or concerns about involving family members in their service. Skilled practice using role-play often took part in the meetings as a way of enabling staff to build confidence in tackling new and sometimes challenging scenarios involving family members in a session. Following the consultancy period the teams attended a one-day follow-up training event with the research team at Head Office. This was an opportunity for teams to receive refresher training in the two interventions. This event was tailored to the staff’s requirements. Staff were asked to provide feedback during the supervision meetings on areas they would like to be addressed at the follow-up event.

6 Project timeline Training & supervision period IMMEDIATE TRAINING
Follow-up period Baseline IMMEDIATE TRAINING 2 teams Pilot study (2 teams) Random assignment 4 teams Training & supervision period CLAIRE TO PRESENT THIS SLIDE This slide presents the overall project timeline for the project. Six teams were involved – two teams were trained at each stage. Phase I: The pilot teams first received the 9-month training package. The teams were then followed up for nearly two years after the end of the input from the research team. This allowed long-term follow-up of the effects of the project to investigate the whether any changes as a result of the project were sustainable over time. During the pilot phase, baseline measures were collected from the remaining four teams. Phase II: The immediately trained teams then received the training package. The same period of 9-months was the baseline (or wait-list) comparison period for the delayed teams. Increases in staff attitudes and levels of family-focused practice during the immediate teams training period could then be attributed to the effect of the IFMO training and on-going supervision if no changes were evident within the delayed teams waiting period. 2 teams Baseline period DELAYED TRAINING

7 Evaluating the impact of the project
Two questionnaires measuring professionals’ attitudes towards family-focused practice (pre, post, and follow-up) Attitudes to Addiction Related Family Problems Questionnaire (AAFPQ) Attitudes to Involving Family Members in Treatment Questionnaire (AIFMTQ) ‘Diary-snapshot’ – to assess changes over time in staffs’ weekly activity Qualitative analysis of professionals’ comments during consultancy supervision meetings CLAIRE Staff attitudes have been found to be important in influencing the extent to which information is accepted and applied. Using the AAFPQ, Copello et al, (2000) found that attitudes and motivation towards working with FMs improved as a result of training and taking part in a specialist training package The AAFPQ has 24 questions divided into six subscales: Knowledge, Confidence, Support, Legitimacy, Motivation, Self-belief and Impact on the user. During early stages of the pilot phase it became apparent that the AAFPQ was lacking in certain ‘family-specific’ questions e.g. asking staff whether working with FMs was as important as working with the focal client, or if involvement of FMs in treatment should be the norm. Items such as these were particularly relevant when encouraging services to respond to the needs of FMs in their own right (Orford et al., 2005). The development of this measure is discussed in the next slide. To assess whether levels of family-focused practice had increased as a result of being involved in the project, a suitable diary-based measure entitled the ‘diary-snapshot’ was piloted and developed during the pilot phase. Data collection and analysis involved randomly choosing two staff per week from each team for a period of 20 weeks to complete a standard form. To understand how staff felt the project had impacted on their role, team and the organisation as a whole, comments provided by staff during their supervision meetings were qualitatively analysed.

8 Training & supervision Training & Supervision
Phase two results: Staff attitudes (AAFPQ) Training & supervision period Follow-up period * Baseline period * FU IMMEDIATE TRAINING PI B1 Mean total AAFPQ Score * Baseline period Training & Supervision period * PI CLAIRE Immediate teams: Significant increase total AAFPQ score between July 2009 and May 2010. Significant increases in total score July 2009 and March 2011. No differences in total score between May 2010 and Mar 2011. Delayed teams: No differences between May 2010 and Mar Significant increase from July 2009 to May 2010 for staff who provided data for both (no differences between independent samples) B1 B2 DELAYED TRAINING *Significantly greater than baseline B1=Baseline 1 B2=Baseline 2 PI=Post-intervention FU=Follow-up

9 Diary-snapshot results: phase two
IMMEDIATE TRAINING Training & supervision period Follow-up period Proportion (%) of family-focused practice Training & supervision period Baseline period CLAIRE Following the pilot phase, the pilot teams had achieved a proportion of 54% family-focused practice. We can see here there was a decrease in these levels following the end of the input from the research team. Despite the decrease, the proportion does stabilize between 23 – 38% on average during the follow-up period. For the immediately trained teams we see significant increases in levels of family-focused practice during the training and supervision period, which although experiences a slight dip following the end of the research team input continues to increase during the later stages of the follow-up period For the delayed teams there are no changes in levels of family-focused practice during the comparison wait-list baseline period. We do see increases in family-focused practice, albeit slow, towards the end of the project. DELAYED TRAINING

10 Overall proportion of family-focused practice
*^ * *Significantly greater than baseline. ^Significantly greater than training period.

11 Qualitative analysis: Main themes
Policy and procedures impeding family-focused practice “It doesn’t just fit into the cycle we’re funded for”  A need to improve outcomes for all “I had a session where a Mother and Daughter let some stuff out [in the session]. At the end of it they got up and hugged each other, apparently for the first time in 5 years” Recognising changes needed in practice and policy ‘Admin will be amending the wording of the invitation letter to show clients that their FMs are welcome in the sessions’ Perceiving and experiencing challenges and difficulties “We’ve had it rammed down our throats careful of the confidentiality, careful not to give anything away” Efficacious impact of the project “Nothing comes of a one-off model workshop. It needs a follow-up intervention.’ ‘The meetings are a useful as a constant reminder. It’s good having the contact” Working creatively and flexibly ‘The confidentiality form is a useful tool rather than a formality…I ask them [focal client] if your brother called me, could I talk to him? I’m proactive in searching around” EXTERNAL Individualistic practices remain “A one-to-one can be quite precious and that’s my preference to working” INTERNAL Limited family-focused practice within outside organisations “GPs only refer drinkers, they don’t think about the affected family members”

12 Drivers for family work integration
Permission to work in family focussed way Open flexible attitude vs ‘opening a can of worms’ Management ‘buy in’ Family work protagonists / ‘champions’ Follow up in supervision / team meetings Addressing issues between consultancy sessions eg first appointment letter

13 Training needs 1-1 work vs 2+ clients in the room
Working with FM’s in own right vs seeing FC and FM’s together Openness to looking for opportunities for family work Complex family therapy vs quick wins Family work = more work vs same/less work Selling family work to service users Confidentiality Conflict and communication issues How to deal with unsupportive network members No support network

14 Conclusions Study supports the use of an Organisational platform to promote the inclusion of affected family members within addiction treatment Significant improvement in staff’s attitudes towards family-focused practice Significant increase in % of family-focused practice across the Organisation (19% at baseline to 34% post-intervention) Number of family workers increased from 9 – 14 during the project Increases in positive attitudes and family-focused practice cannot be fully attributed to the training element of the project Culture change permeating the whole Organisation? CLAIRE? This study provided a broad range of findings and highlights the usefulness of the approach in being able to identify the barriers and facilitators to successful implementation of family-focused practice. The theory and findings produced here are part of an on-going process for the organisation, and lessons learned are useful in helping to determine improved outcomes in implementation of family-focused practice going forward. Results indicated that routine addiction services are capable of implementing family-focused practice, however, the success of implementation depends on many organisational factors as well as individual service provider characteristics. Using a mixed-method design is essential when evaluating such interventions. The quantitative data provided the overall picture of changes in staffs attitudes towards working with FMs as well as demonstrating changes in behavioural practice that had taken place as a result of the project. The qualitative data further illustrated the complex and sometimes hidden feelings from the staff, helping to often support the statistical findings, as well as aiding the interpretation where attitudes failed to significantly increase.

15 Teams and Organisations or the wider health system both?
Some final thoughts….. Teams and Organisations or the wider health system both? ALEX? This study supports the use of an organisational platform to understand how to successfully implement change within routine addiction services towards becoming a more family-focused service. Findings highlight the need to be mindful of the strong influence of the practice environment when trying to implement new innovations. Beyond the attitudes and skills of individual professionals, it is clear that organisational culture and climate exert considerable influence on the successful implementation of family-focused practice. Staff often appeared to be ‘at their limits’ and often perceived family work as taking on ‘additional work’. It is crucial, therefore, that going forward the organisation ensure that family work is incorporated into existing structures. Finally, it is important that commissioners also carefully consider the complexities involved in developing a more family-oriented service and are open to supporting these developments. In conclusion, the results of this project suggest that successful implementation of family-focused practice requires more than a training package alone. Although the training package was able to successfully increase levels of family-focused practice as well as staff’s attitudes towards working family-inclusively, to ensure long-term sustainable effects of such a project also depends on complex provider and organisational characteristics such as leadership, competing priorities, time availability, resources and funding, and should be taken into consideration when planning such interventions.

16 Thank you for listening For more information, please contact: Richard McVey: Claire Hampson:

17 References Copello A, Templeton L, Krishnan M, Orford J, Velleman R. (2000a). A treatment package to improve primary care services for the relatives of people with alcohol and drug problems. Addiction Research, 8, 471 – 84. Copello, A. & Orford, J. (2002). Addiction and the family: is it time for services to take notice of the evidence? Addiction, 97, 361–1363. Copello, A., Orford, J., Velleman, R., Templeton, L., & Krishnan, M. (2000b). Methods for reducing alcohol and drug related family harm in non-specialist settings. Journal of Mental Health, 9, Copello, A., Velleman, R., Templeton, L. (2005). Family interventions in the treatment of alcohol and drug problems. Drug and Alcohol Review 24, (4), Orford J., Natera, G., Copello, A., Atkinson, C., Mora, J., Velleman, R., el al. (2005a). Coping with alcohol and drug problems: The experiences of family members in three contrasting cultures. London: Brunner-Routledge. Orford J., Natera, G., Davies, J., Nava, A., Mora, J., Rigby, K., Bradbury, C., Copello A. & Velleman, R. (1998a). Stresses and strains for family members living with drinking or drug problems in England and Mexico. Salud Mental V, 21, No. 1. Orford, J., Natera, G., Davies, J., Nava, A., Mora. J.. Rigby, K.,Bradbury, C., Bowie, N., Copello, A. & Velleman, R.(1998b) Social support in coping with alcohol and drug problems at home: findings from Mexican and English families. Addiction Research, 6, Orford, J., Templeton, L., Velleman, R. & Copello, A. (2005b). Family members of relatives with alcohol, drug and gambling problems: a set of standardised questionnaires for assessing stress, coping and strain. Addiction, 100, Roberts, M., Klein., A. & Trace, M. (2004). Towards a Review of Global Policies on Illegal Drugs. Drugscope – Report 1, 1 – 8. UKATT Research Team (2005). Effectiveness of treatment for alcohol problems: findings of the randomised UK Alcohol Treatment Trial. British Medical Journal; 331, 541–544. Velleman, R., Templeton, L., Group, U. K. A. D. a. t. F. R., (2003). Alcohol, Drugs and the Family: Results from a long-running research programme within the U.K. European Addiction Research, 9 (3),

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