Kith & Kin

1. Kith & Kin & Colleagues?

2. Kith & Kin – and Colleagues? • The effects, consequences and inter-relationships between chemical dependency and family dynamics have been studied over the years from a variety of angles – both in terms of causative factors for substance use and as consequences of it.

3. Definitions: • “Addiction” is non scientific. The same can be said for “alcoholism”. We have criteria for drug dependency and abuse; alcohol dependency and abuse – DSMIV – yet we also throw around Drug Misuse, Problematic Drug Use and even Binge Drinking- usually without much distinction often interchangeablely or without any clear understanding.

4. Definitions “2” • Even the word “family” can have varying meanings: • “Family of origin” • “Current Family” • “Significant Others” • Use of “genogram” in treatment. • A Google search gave 27 English Language definitions of addiction. No wonder then that treatment and/or recovery is seen as difficult if there is no common definition as to what the problem is!

5. Predictive/Causative Factors Protective factors: • strong and positive family bonds; • parental monitoring of children's activities and peers; • clear rules of conduct that are consistently enforced within the family; • involvement of parents in the lives of their children; • success in school performance; strong bonds with institutions, such as school and religious organizations; and • adoption of conventional norms about drug use.

6. Predictive/Causative Factors(2) Risk factors: • chaotic home environments, particularly in which parents abuse substances or suffer from mental illnesses; • ineffective parenting, especially with children with difficult temperaments or conduct disorders; • lack of parent-child attachments and nurturing; • inappropriately shy or aggressive behavior in the classroom; • failure in school performance; • poor social coping skills; • affiliations with peers displaying deviant behaviors; and • perceptions of approval of drug-using behaviors in family, work, school, peer, and community environments.

7. Predictive/Causative Factors(2) • The preceding 2 slides were taken from the US National Institute on Drug Abuse: http://www.nida.nih.gov/NIDA_Notes/NNVol16N6/Risk.html • Please note that the above refers to substance use – not substance abuse or substance dependency

8. GENETICS • It has been. established in various research including Cotton (1979) that alcoholism and other drug abuse is familially transmitted. Several studies of alcoholic groups have reported alcoholism rates of 50% among their fathers, 30% among their brothers, and 6% among their mothers(Goodwin, 1980). Among first- and second-degree males relatives, the risk is 25% (Cotton, 1979)

9. Predictive/Causative Factors(3) • For an up to date summary of the research see “The Science of Addiction” – From Neurobiology to Treatment by Carlton K. Erickson – WW Norton – 2007. • Attachment Theory – Thomas Hedlund et al See http://www.thomashedlund.com

10. Families and Addiction: • Contrary to widely held belief, alcoholics and other drug abusers are far more often found in the context of intact family situations than on Skid Row. Only a minority of addicts live in social isolation and homelessness (World Health Organization, 1977)

11. Family Adaption: • The family of the addict is characterized by denial(Bean, 1982). There is an atmosphere of shame (Arentzen, 1978) and an underlying core of fear and tension. In most alcoholic families, there is a major secret. The maintenance of that secret, the alcoholism, is the central focus around which the family is organized (Brown and Beletsis, 1981)

12. Characteristics of Families with Addiction • Chaos • Inconsistency • Unclear roles • Unpredictability • Arbitrariness • Changing limits • Repetitiousness • Illogical arguments • Violence (sometimes incest) (Beletsis and Brown, 1981)

13. Enabling Behaviours Enabling behaviours allow the addicted person to continue with the addiction. It feels helpful, but it promotes the addiction and the denial that is so crucial to the process. • Examples: • Making excuses for the addict • Paying their bills • Bailing them out of jail • Making rationalizations for irresponsible behaviours • Ignoring the problems caused by the addict's use • Cleaning up their messes • Accepting their excuses or believing their lies • Not discussing the problem • Not getting help for themselves

14. Why work with families? • Family interventions are indicated in circumstances in which the patient's abstinence upsets a previously well-established but maladaptive style of family interaction and in which other family members need help in adjusting to a new set of individual and familial goals, attitudes, and behaviors.(APA, 2004)

15. Why work with families? • Family therapy that addresses interpersonal and family interactions leading to conflict or enabling behaviours can reduce the risk of relapse for patients with high levels of family involvement. Couple and family therapy are also useful for promoting psychological differentiation of family members, providing a forum for the exchange of information and ideas about the treatment plan, developing behavioural management contracts and ground rules for continued family support, and reinforcing behaviours that help prevent relapse and enhance the prospects for recovery. (APA, 2004)

16. Family Roles Family members in addict families take on roles. Based on the work of Virginia Satir, Wegshieder-Cruse(1985) proposed that the roles in these families are: • Hero • Scapegoat • Lost child • Mascot • These “roles” are learnt in the family and are taken on as a means of survival in the family. Learnt in childhood they are carried forward into adult life – influencing relaionships, carer choices etc

17. Adult Children of Alcoholics: • 1. Guess at what normal is.2. Have difficulty in following a project through from beginning to end.3. Lie when it would be just as easy to tell the truth.4. Judge themselves without mercy.5. Have difficulty having fun.6. Take themselves very seriously.7. Have difficulty with intimate relationships.8. Overreact to changes over which they have no control.9. Constantly seek approval and affirmation.10. Feel that they are different from other people.11. Are either super responsible or super irresponsible.12. Are extremely loyal, even in the face of evidence that loyalty is undeserved.13. Have money dsyfunction, such as hiding it or being disorganized with it.

18. Codependents: • Think and feel responsible for other people---for other people's feelings, thoughts, actions, choices, wants, needs, well-being, lack of well-being, and ultimate destiny. • Feel anxiety, pity, and guilt when other people have a problem. • Feel compelled - almost forced - to help that person solve the problem, such as offering unwanted advice, giving a rapid-fire series of suggestions, or fixing feelings. • Feel angry when their help isn't effective. • Anticipate other people's needs. • Wonder why others don't do the same for them. • Don't really want to be doing, doing more than their fair share of the work, and doing things other people are capable of doing for themselves. • Not knowing what they want and need, or if they do, tell themselves what they want and need is not important. • Try to please others instead of themselves. • Find it easier to feel and express anger about injustices done to others rather than injustices done to themselves. • Feel safest when giving. • Feel insecure and guilty when somebody gives to them.

19. Codependents • Feel sad because they spend their whole lives giving to other people and nobody gives to them. • Find themselves attracted to needy people. • Find needy people attracted to them. • Feel bored, empty, and worthless if they don't have a crisis in their lives, a problem to solve, or someone to help. • Abandon their routine to respond to or do something for somebody else. • Overcommit themselves. • Feel harried and pressured. • Believe deep inside other people are somehow responsible for them. • Blame others for the spot the codependents are in. • Say other people make the codependents feel the way they do. • Believe other people are making them crazy. • Feel angry, victimized, unappreciated, and used. • Find other people become impatient or angry with them for all of the preceding characteristics.

20. ACOA/Nursing Study • The purpose of this study was to determine the incidence of adult children of alcoholics (ACOA) among the students and faculty in a Midwestern diploma school of nursing. The sample included 201 students and 17 members of the faculty. The instrument used was the Children of Alcoholics Screening Test(C.A.S.T.) (Jones, 1981). A questionnaire to elicit demographic and self-report data regarding the participant's marital starus, drinking patterns and level of concern over personal drinking behavior was also administered. Analysis indicated 23% of the overall sample were ACOA and 8% were children of problem drinkers. In the student sample, 23% were ACOA and 8% were children of problem drinkers; 29% of the faculty were ACOA and 6% were children of problem drinkers. The total C.A.S.T. (Jones, 1981) score was significantly greater in those subjects who identified either parent as alcoholic. • http://hdl.handle.net/2092/510

21. Hypothesis: • People from addictive family backgrounds are more likely to find their way into work in the caring professsions in general & particularly AOD services. • They will bring any unresolved family of origin issues/roles with them into the workplace. • These can be “acted out” in their relationships with clients. • This will impact on the quality of service delivery and treatment outcomes.

22. Worrying trends: • “Service User Involvement”- often becomes little more than a vehicle for staff recruitment/volunteer recruitment where the needs of the organisation get put before the needs of both current and recent clients. ie it can be exploitatative. • Family and Carers – often services can do the same thing here, seeing family members as helpers rather than clients.

23. Worrying Trends (2) • Services are driven by “contract culture” • Services are driven by “targets” as part of the above and targets are often inappropriate and serve no useful purpose in terms of service development. • Outputs rather than Outcomes • Staff increasingly become unpaid bureaucrats – monitoring and data collection hinders the therapeutic alliance. • Managing growth and “founders syndrome”

24. Warning Signs • Stress becomes distress • Team members fall back into family of origin roles. • “5 year big bang theory” • “My clients” • Possesiveness • Secrets • Collusion with clients

25. Warning Signs (2) • Boundaries • Time – workaholism • Personal details (home phone number) • Health and Safety: • Home Visits • Putting self and agency at risk • Catering to the addiction: • Appointment times • Lifts • Taking “responsibility” for “my clients” rather than giving them opportunities to learn to take responsibility for themselves.

26. Some Suggestions: • Organisations need Strong Boards, CEO’s are as prone to be dysfunctional as everybody else. Possibly more so! • Focus on quality, not quantity. Quality of staff service delivery – not the growth of the staff team. Staff Retention not expansion. • Have policies that are more than paper to please the commissioning managers.

27. Some Suggestions (2) • Separate Supervision from line management. The 2 are different functions and don’t always mix. • Have staff support groups, not just team meetings. Use an “outside” facilitator. • The staff represent 70% of the assets of any treatment service. Invest in training. • Develop staff retention strategies.

28. Final Thoughts:- • I have seen it said that the career span of most people in the AOD treatment field is around 5 years from beginning to end. This means that the average client uses drugs for much more time than the average worker will last around the addiction field. Ask yourself why. • An agency cannot treat its clients better than it treats its staff.

29. Contact Details • John Chamberlain • The Alchemy Project Ltd • john.chamberlain@alchemyproject.co.uk • 07970 944907