Involving Family Members in Services and Recovery

1. Involving Family Members in Services and Recovery Prof Alex Copello Consultant Clinical Psychologist Addiction Services Birmingham and Solihull Mental Health Foundation Trust & Professor of Addiction Research The University of Birmingham a.g.copello@bham.ac.uk Presented at Society for the Study of Addiction Annual Symposium 2008 Addiction Across the Lifespan 13th and 14th November, Park Inn York, York, UK

2. Involving Family Members Project Group • Jim Orford • Lorna Templeton • Akan Ibanga • Richard Velleman

3. 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 and Copello et al., 2006]

4. 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 substance abuseRay et al (2007) The excess medical cost… Medical Care

5. 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]

6. TREATMENTS INVOLVING FAMILY MEMBERS (FMs) A. Working with FMs to encourage their relatives’ engagement in treatment e.g. Family ‘intervention’; Community reinforcement and family training; Unilateral family therapy; Cooperative counselling; Pressures to change B. Joint involvement of FMs and their relatives in their relatives’ treatment e.g. Conjoint family group therapy; Behavioural couples therapy; Family therapy; Network therapy; Social behaviour and network therapy C. Responding to the needs of family members in their own right e.g. Concurrent group treatment; Al-Anon, Families Anonymous; Supportive stress management counselling; Parent coping skills training; 5 step intervention

7. NTA Guide for commissioners and providers1.1. Key messages • Providing services to meet the needs of families and carers leads to improvements for families, carers, children and drug misusers • Areas without provision, or with limited provision, can benefit from developing or expanding services for families and carers • Developing a family-friendly focus will assist providers to achieve the best outcomes for users and carers • Involving families and carers can improve engagement, retention and outcomes for drug users in treatment • Involving families and carers in the planning and commissioning of services improves the effectiveness of services and the drug treatments system Taken from Supporting and Involving Carers: A guide for commissioners and providers published by the National Treatment Agency 2008, p.7

8. IMPLEMENTATION

9. Addiction and the family: is it time for services to take notice of the evidence? (Copello and Orford, Addiction, 2002) POTENTIAL BARRIERS Theoretical Practical Treatment focus needs to be broadened Commissioners and service providers recognition of broader sets of outcomes

10. Levels of dissemination of family focused work • Individual volunteer service providers • Service providing units or teams • Whole services or agencies • Dissemination on a motivational level

12. The 5 Step Intervention

13. Copello, Templeton, Orford et al. (5-STEPS) – family member focused • Listen non-judgementally • Provide information • Discuss ways of responding • Explore sources of support • Arrange further help if needed

14. 5 Step Intervention: Changes in symptomsCopello, Templeton, Orford et al., (in press) Addiction

15. 5 Step Intervention: Changes in Coping Behaviours Copello, Templeton, Orford et al., (in press) Addiction

17. Social Behaviour and Network Therapy (SBNT) – user focused • A Manualised time limited intervention consisting of 8 sessions • Based on the principle that social behaviour, social interaction and network support for change play a central part in the resolution of addiction problems

18. Percent Days abstinent Ukatt – United Kingdom Alcohol Treatment Trial: BMJ, 2005, 331, 541-544 & 544-548

19. Drinks per drinking day Ukatt – United Kingdom Alcohol Treatment Trial: BMJ, 2005, 331, 541-544 & 544-548

20. The four most important people: how were they related to the problem drinker? (from UKATT, N = 742) This graph shows how the participants were related to their four most important people. Percentages of named relationships are shown for the 1st, 2nd, 3rd and 4th most important people to the focal drinker:

21. Key aspects of a network approach • Identify network • ‘Think network’ • Agree goals • Explore and enhance (if possible) communication • Explore coping • Joint activities • Relapse management and responses

22. Birmingham Alcohol, Drugs, Gambling & Addiction Research Group

23. Objectives: To obtain agreement of two specialist treatment teams To establish organisational standards for the engagement of families To train managers and frontline staff To evaluate the results: Establishment of standards Take up of training Change in frequency of engagement of family members Changes in attitude

25. Methods of evaluation • Process Notes • Collection of practice case examples • Inventory of new practices • Individual interviews with team members • Focus groups • Attitude change • Auditing involvement of family members

26. The project timetable

27. Some initial concerns • Negative for FC if limited network • FMs don’t want to get involved • Takes more time and logistic problems • Lack of experience of working with more than one person • Concern about confidentiality • Danger of conflict or FM taking over • May be conflict of interest for counsellor • Might open Pandora’s box of family issues

28. Seeing the benefits of IFM • FC appreciates who might be supportive • Counsellor can get a fuller, clearer picture • FMs help as co-workers • FMs feel listened to and have a role • FMs are better informed • Conflict can be managed and eased • Family support extends beyond treatment

29. Diversity of family members Wife... Husband… Fiance… Mother & father of 18 year-old… Brother &15 yr-old son… Daughter of 70 yr-old… Son & daughter… Mother & sister… Wife, sister & brother-in-law… Mother & brother… Sister, aunts & uncles… Mother & two brothers… Uncle & brother’s wife… A friend… Two neighbours

30. Diversity of form & sequence of work with family members • Brief meeting before session with FC • 4 sessions with FC followed by one joint • 3 sessions with a couple followed by several with FC alone • 1 session with FC & partner followed by large family meeting • Home detox: 5 sessions joint with spouse and sometimes other FMs • FC alone, then with mother, then with father, then alone • Arrest referral: 1 joint session, 1 FC alone

31. Diversity of outcomes • FM calmer, reassured • Support for FC; mutual support • Clear joint goals and plans • Conflict handled in a safer environment • FM less tolerant, more assertive coping • Joint planning of alternative activities • FM increased knowledge of alcohol problems • Better communication and mutual understanding • Realising children also affected • FM decided to stay

32. Percentage of contacts involving family members over a two week period

33. System-level changes: Did they happen? • New initial appointment letter • Leaflet for FMs • New client assessment form • New family-oriented records • Log of informal family contacts • Recording family work in the new electronic data base

36. Notes: 1Significantly greater than before the project (confidence, knowledge, support, impact, legitimacy and total at p<0.001; self-belief at p<0.01; motivation at p<0.05). 2Significantly greater than comparison teams (support at p<0.01; knowledge and total at p<0.05).

37. Lessons we learnt • Be clear about aims • Be sensitive to differences in people’s levels of previous training and experience of family work • Be aware of limitations in the organisation’s capacity to record family work

38. Some continuing issues • Striking a balance between seeing different members of the family together or separately • How best to explain to FCs and FMs why involving FMs is being recommended • Whether to involve FMs when cases appear complex • Involvement of children and young people • Joint work with other agencies

39. Limitations • Representativeness of teams • Length • Methods of evaluation • No family member outcomes

40. Thank you for listening…