Supporting families whose lives are affected by alcohol or drug problems :

Supporting families whose lives are affected by alcohol or drug problems: Goa Psychiatric Society meeting Panjim, Goa, Thursday, 21st June 2012 Professor Richard Velleman Emeritus Professor of Mental Health Research, University of Bath / Avon & Wiltshire Mental Health Partnership NHS Trust, UK

Supporting families whose lives are affected by alcohol or drug problems I want to ask 5 questions this evening: • What is known about the effects on families; • What are the specific needs that children in these families have (and is there evidence of inter-generational transfer of poor outcomes, including substance misuse?); • What can we do to help families;

Supporting families whose lives are affected by alcohol or drug problems • What can we do specifically to help children (and how might we break the inter-generational links); and • How effective are interventions for children and which seek to break these links?

Supporting families whose lives are affected by alcohol or drug problems Acknowledgments: In Bath, Lorna Templeton (15 years); In Birmingham (and Exeter before that), Jim Orford (35 years), Alex Copello (21 years); Internationally, In Mexico, Institute of Psychiatry, Mexico City, Guillermina Natera, Jasmin Mora, Marcela Tiburcio; In Australia, Darwin, Northern Territory, Ian Crundall, Carol Atkinson; In Italy, Caterina Arcidiacono.

Supporting families whose lives are affected by alcohol or drug problems 1. What is known about the effects on families? Lots of families have lives which are very negatively affected by substance misuse, all across the world – we have studied this in the UK, in Mexico, in Australia in the aboriginal outback, in Italy, but others have looked at this also, and the conclusion is the same: Family members (especially spouses and parents and even more so, children) are often very badly affected by having someone with a serious drug or alcohol problem living in their midst.

Supporting families whose lives are affected by alcohol or drug problems There is a solid evidence base for this claim: I list at the end of this talk many references which people can follow up if they want to. In addition, there is a solid evidence base for the impact of substance misuse on children, both as children and when adults. There are a very large number of studies that demonstrate negative effects on children whilst they are still young and in early adolescence (again, reviewed a number of times, see the references at the end).

Supporting families whose lives are affected by alcohol or drug problems All this work has led to the following conclusions: Individuals who develop a serious problem with their use of alcohol or drugs can and often do behave in ways that have a significantly negative impact on family life in general, and on other individual members of the family. The substance misuse can impact negatively on a range of family systems and processes, including family rituals, roles within the family, family routines, communication structures and systems, family social life, and family finances.

Supporting families whose lives are affected by alcohol or drug problems The substance misuse can also often impact negatively on other individuals within the family, as well as on family systems: problems such as • domestic and other types of violence, • child abuse, • individuals driving whilst intoxicated, • or disappearing for days on end, • or embarrassing family members, • or spending all the money so that there is nothing left for the family are all typical of the types of behaviour which people have described as stressful and with which they have to cope.

Supporting families whose lives are affected by alcohol or drug problems The results of these and other uncertainties are that family members commonly develop problems in their own right, often manifested in high levels of physical and psychological symptoms.

Supporting families whose lives are affected by alcohol or drug problems 2. What are the specific needs that children in these families have (and is there evidence of inter-generational transfer of poor outcomes, including substance misuse?) These things are often worse for the children. Many of these children experience negative childhoods, including • violence, abuse and living with fear; • inconsistency from one or both parents; (more)

Supporting families whose lives are affected by alcohol or drug problems • having to adopt responsible or parenting roles at an early age • having to deal with denial, distortion and secrecy; • having problems related to attachment, separation and loss; • disturbed family functioning, conflict and breakdown; • role reversal and role confusion, both related to their parents, and themselves.

Supporting families whose lives are affected by alcohol or drug problems Many of these children subsequently demonstrate negative effects of these experiences. These problems include • higher levels of behavioural disturbance, • anti-social behaviour (conduct disorder), • emotional difficulties, • school problems, • ‘precocious maturity’, • and a more difficult transition from childhood through adolescence, than children who have not had this upbringing.

Supporting families whose lives are affected by alcohol or drug problems Other work has also shown that children affected by parental substance misuse are more likely to reach the attention of social services than are children affected by other issues, and when they do so, and are more likely to experience problems in the interaction between their parents and social services than occurs with other types of problem.

Supporting families whose lives are affected by alcohol or drug problems There are longer-term impacts on these children: • more likely to themselves develop problems with substances, • often linked to earlier onset of use, • and therefore at greater risk of developing problems in other areas of life as adults. Family factors predominate: family dysfunction and disharmony in their family of origin seems most responsible for problems for these children, both when they are children, and later as adults, as opposed to problems caused by the drinking itself.

Supporting families whose lives are affected by alcohol or drug problems HOWEVER, there is growing evidence that not all children are adversely affected, either as children or adults; some children are resilient and do not develop significant problems. This has important implications for prevention and intervention, and I shall return to this later. SO - family members suffer lots of stresses as a result of living in this environment, which may impact on physical and mental well-being and lead to the development of problems both for themselves and other family members.

Supporting families whose lives are affected by alcohol or drug problems This is a world-wide phenomenon: we have found remarkably similar sets of experiences and effects across the world. And these family members need help, both for themselves, and in relation to dealing with their substance misusing relation. And they ask for this help! Between a third and a half of calls to alcohol advice centres in the UK come from partners, families and friends.

Supporting families whose lives are affected by alcohol or drug problems 3. What can we do to help families? There are three sorts of things that can be done to help families. We can • work with family members to promote the entry and engagement of misusers into treatment, • develop joint involvement of family members and misusing relatives in the treatment of the misuser; • respond to the needs of the family members in their own right. All three have been tried, and all three work!

Supporting families whose lives are affected by alcohol or drug problems Working with family members to promote the engagement of substance misusers into treatment • John Donne declared many years ago that ‘No man is an Island’ and this is true! People develop problems and maintain them within a social context, and the family is part of this social context. • So, not surprisingly, involving the family member means that it is more likely that alcohol or drug misusers will then engage in treatment. Basically, the family member can influence the person with the alcohol or drug problem by helping them to decide to seek or accept help for the problem.

Supporting families whose lives are affected by alcohol or drug problems Lots of people have developed ways of doing this, and many of them have been well researched (and see my reviews on this, in the reference list). For example, Barber and Crisp (1995) developed the ‘pressures to change’ approach, which starts by engaging the family member: work with them is focused on • education; • discussion of their responses to drinking situations; • setting up activities incompatible with drinking; and

Supporting families whose lives are affected by alcohol or drug problems • and preparing the family member to confront the person with the drink problem and request that he/she approaches services to seek help. In essence the approach aims to create change in the behaviour of those concerned in order to achieve treatment entry for the person with the drink problem.

Supporting families whose lives are affected by alcohol or drug problems Another example is the CRAFT approach (Community Reinforcement and Family Training), developed by Bob Mayer and Bill Miller. This also aims to • work with ‘concerned significant others’ (CSO’s), helping them to reinforce non-substance misusing behaviour through a positive reinforcement process, • and involves the restructuring of social, family and vocational aspects of everyday living of those with substance use problems, so that abstinence from drugs or alcohol is selectively encouraged.

Supporting families whose lives are affected by alcohol or drug problems There have been many other interventions such as these developed, in the USA, Australia and the UK, all aimed at getting ‘treatment-resistant’ substance misusers into treatment: and lots of research has shown that these approaches work. Eg: • ARISE programme • Network Therapy • co-operative' counselling service • The Johnson’s intervention

Supporting families whose lives are affected by alcohol or drug problems Research consistently shows that working directly with those concerned about someone else’s substance use can lead to engagement of the user in treatment, and stress the influential role of family members in relation to treatment entry of the substance user. These results have been replicated across various groups of family members using a range of substances, although more, and more rigorous, controlled evaluations have been conducted in the alcohol area than in the drugs area.

Supporting families whose lives are affected by alcohol or drug problems These findings challenge the powerful myth, widely held within the substance misuse problems and therapy field: that family members concerned about a relative’s substance misuse cannot influence someone with a substance misuse problems to change. It is true that family members cannot make an individual stop drinking or using drugs, but they can change their own behaviour in ways that will help the misuser recognise that the substance use is problematic, and that change is desirable.

Supporting families whose lives are affected by alcohol or drug problems Further, if interventions are offered to family members in their own right (eg to help them cope better, or help them develop improved social networks), there are significant effects in terms of reduced symptoms and altered coping mechanisms which in turn impact on the drinker’s behaviour.

Supporting families whose lives are affected by alcohol or drug problems Joint Involvement of family members and substance misusing relatives in treatment OK – involving family members means that reluctant substance misusers are more likely to be drawn into and engaged within treatment services. That’s great, but what about the effectiveness of these treatments: are treatments more or less effective if family members are involved? The answer is that family involvement leads to more effective services: there are greater reductions in levels of both consumption and of problems.

Supporting families whose lives are affected by alcohol or drug problems Some more detail. It has been known for some time that the quality of family relationships impacts on someone’s substance misuse and that positive marital and family adjustment is related to positive treatment outcomes. There are also a number of examples of studies showing that involvement of ‘concerned others’ in behavioural, community-reinforcement and family approaches leads to improved outcomes in both alcohol treatment and drug treatment.

Supporting families whose lives are affected by alcohol or drug problems Basically, lots of systematic reviews have shown that treatments which involve people’s social context (eg Community Reinforcement, Behavioural Marital Therapy) are both highly effective, and also more cost-effective. In fact, family involvement leads to better outcomes even if the substance misuser does not attend! One of the most interesting approaches (and one which demonstrates how much families do work as a system) is Unilateral Family Therapy.

Supporting families whose lives are affected by alcohol or drug problems UFT uses a systemic model that suggests it is possible to alter the ways that a family works, without all members of the family system being present in therapy sessions, and they have shown that it is possible to alter someone's substance misuse even if that person never presents for treatment. This approach was designed to be most suitable for attracting the most "unmotivated, treatment-resistant [misusers]".

Supporting families whose lives are affected by alcohol or drug problems Working with other members of the system and helping them to change their behaviour impacts on the user's behaviour as well. This approach uses the concerned family member alone, aiming to affect change through working with the family member (often a spouse) in the absence of the person with the problem.

Supporting families whose lives are affected by alcohol or drug problems And it works: one study showed a 53% reduction in alcohol consumption in those users whose family members received the intervention, and a slight increase in consumption in the control group; and that for over 50% of the problem alcohol users whose family member received treatment, the drinking was reduced or the drinker entered treatment compared to none in the control group. In another study, 57% of misusers entered treatment compared to 31% in the no-treatment control condition.

Supporting families whose lives are affected by alcohol or drug problems All this suggests that there are a set of therapeutic strategies which can help the family respond constructively to a family member's substance misuse problem and motivate the misuser to change or seek treatment, even if they themselves do not attend for help. Of course, most family interventions do not work by working with the family member alone, and many do not aim solely to reduce substance use:

Supporting families whose lives are affected by alcohol or drug problems they focus on improving relationships, decreasing behaviours that facilitate substance misuse, and increasing marital or family stability and happiness. Many approaches focus on interactions between family members and substance misusers more directly, maybe by using Behavioural or Cognitive-Behavioural Couples Therapy or Family Therapy (lots of evidence to show that both of these are often very effective).

Supporting families whose lives are affected by alcohol or drug problems Major components of substance-focused behavioural couples therapy include: • Cognitive-behavioural strategies that will help the misuser stop using and acquire coping skills to respond to both substance-specific and general life problems; • Strategies that teach family members to support the misuser’s change efforts, reduce protection for substance-related consequences, develop better skills to cope with negative emotions, and communicate around substance-related topics; • Strategies to improve the couple's relationship by increasing positive exchanges and improving communication and problem-solving skills; • Behavioural contracts between intimate partners to support the use of medication.

Supporting families whose lives are affected by alcohol or drug problems Approaches which involve family members to help the whole family (including the substance misuser) to change positively include: Network Therapy, and Social Behaviour and Network Therapy (SBNT), developed in the UK by my collaborators, Alex Copello and Jim Orford. SBNT is a synthesis of many of the family and social network ideas I have just outlined, and is based on the premise that to give the best chance of a good outcome people with serious drinking problems need to develop positive social network support for change, and this involves getting members of their networks who will support them in changing their behaviour involved in the therapy.

Supporting families whose lives are affected by alcohol or drug problems All these treatments have resulted in either equal or usually better outcomes than approaches that do not involve the substance misuser’s family; most show positive increases in the long term, compared to interventions which do not involve spouses and other family members, or involve them only minimally. Certain approaches stand out. • The Behavioural Marital or Couples Therapy approach • Social Behaviour and Network Therapy (SBNT) • The Community Reinforcement and Family Training (CRAFT) approach

Supporting families whose lives are affected by alcohol or drug problems So – involving family members in Users’ treatment leads to better outcomes. But the focus of all of these approaches I’ve outlined so far is the substance misuser, not the family member. Many of us argue that, because of the harm that is done to family members (both adults and children) family members deserve help in their own right. Interventions aimed at supporting those family members affected by the substance misuse of a relative

Supporting families whose lives are affected by alcohol or drug problems Generally, even in treatments which use family members (to engage substance misusers into treatment, or to effect positive therapeutic change), little or no attention has been paid to the family members, as opposed to the problem drinker or drug user. As examples, until recently most studies of family interventions which aimed at treating substance misusers did not measure changes in symptoms in family members, or change in the family members’ coping behaviours, following a family intervention.

Supporting families whose lives are affected by alcohol or drug problems In addition, the needs of the families of substance misusers have been largely ignored in service provision: there are many services for problem drinkers or drug takers: very few for family members. This is because the primary focus has been on the outcomes for the substance user, with family members being conceptualised (if at all) as adjuncts in the treatment process or agents who can influence the substance user’s behaviour.

Supporting families whose lives are affected by alcohol or drug problems Much of this is due to a hangover from old fashioned models of family functioning which cast family members in a negative light – as the villains, or the cause of the problem. Lots of these theories, usually actually being very gender biased: suggesting that the alcohol or drug problems of men are cause by the ‘bad women’ in their lives: their bad mothers or their bad spouses.

Supporting families whose lives are affected by alcohol or drug problems There is some evidence in England that this is slowly changing: a survey conducted by Alcohol Concern, the English National alcohol agency, in 2004 found 59 agencies which offered some level of help families and/or children and affected by alcohol misuse. This is a marked increase over the numbers in a previous survey in 2000, which found only 14 such agencies in their survey. However, even in this more recent work, 78% of respondents felt that the work that they were able to work with children and families was not meeting the needs which were apparent.

Supporting families whose lives are affected by alcohol or drug problems Although there is such a lack of direct work with families affected by substance misuse, evidence is emerging for the effectiveness of interventions aimed at these family members in their own right. My research group in the UK has undertaken a number of studies of interventions aimed at reducing family members stress and strain. We developed a model of why alcohol & drug problems caused family members problems: the stress-strain-coping-support model (SSCS).

Supporting families whose lives are affected by alcohol or drug problems This suggested that …. Family members are stressed due to the impact of a relative’s substance misuse How the family member copes with (responds to) the situation Strain: usually physical and psychological health problems and The level and quality of social support available to the family member

Supporting families whose lives are affected by alcohol or drug problems Using this, we developed a simple and brief (so it could be delivered in primary care) 5-step therapeutic intervention which worked at each stage of the model. The 5-step approach involving 1) giving the family member the opportunity to talk about the problem; 2) providing relevant information; 3) exploring how the family member responds to their relative’s substance misuse; 4) exploring and enhancing social support; and 5) discussing the possibilities for onward referral for further specialist help.

Supporting families whose lives are affected by alcohol or drug problems In the UK we’ve conducted studies of this 5-Step Intervention in Primary care, and also with a small sample in a specialist Secondary care setting, and in primary and secondary care in Italy. Results from all of these studies are positive. We have demonstrated that the intervention is effective in reducing family members’ signs of strain (a significant reduction in both physical and psychological symptoms) and positively altering and enhancing their coping mechanisms; and in improving their social support.

Supporting families whose lives are affected by alcohol or drug problems Qualitative data have shown that family members greatly appreciate the opportunity that the intervention provides for them to talk about and reflect upon their situation, and consider how positive change can be achieved. Further, we also showed an improvement in the attitudes held and motivation towards working with relatives of substance misusers, in the primary health care professionals involved in delivering the intervention.

Supporting families whose lives are affected by alcohol or drug problems There is also some evidence that the intervention can, in some cases, lead to a change in the problem alcohol or drug consumption of the relative and that this in turn can lead to improved family relationships. Our work is not alone: other work has been undertaken to engage and help family members affected by the excessive drinking or drug taking of close relatives, mainly in other countries: the USA, Australia, Canada and former Yugoslavia.

Supporting families whose lives are affected by alcohol or drug problems One example is the CRAFT approach I described earlier: although designed as a method of improving the engagement of people with substance misuse problems into treatment, it also showed positive effects directly on family members: significant reductions in family conflict, depression, anxiety, anger, and physical symptoms, with average scores dropping into the normal range on all measures, as well as improvements in family cohesion. And these direct and personal benefits to the family members occurred regardless of whether or not their relative did or did not enter treatment.

Supporting families whose lives are affected by alcohol or drug problems Another example is the ‘Parent coping skills training’ programme which aims to teach more effective coping skills in responding to adolescents’ substance use. This work showed greater improvement in parental coping skills, parents’ own functioning, family communication and their adolescent’s drug use compared to waiting list controls. And there have been other successful approaches helping parents to cope with their children’s alcohol and drug use and problems.

Supporting families whose lives are affected by substance misuse OK, to sum up, I asked the question: what can we do to help families. The answer is lots: we can use family members to get resistant substance misusers into treatment and to engage them there, and if we then involve family members in their treatment, both the family members and the users have better outcomes. And if we develop services for family members in their own right, these are often very effective and family members show improved physical and psychological symptoms, better coping, more social support.

Supporting families whose lives are affected by alcohol or drug problems :