“ I do not know what the future will hold, but I know there is hope .” ENGAGING FAMILIES

1. “I do not know what the future will hold, but I know there is hope.”ENGAGING FAMILIES Tommie Ann Bower Chief Clinical Officer Gosnold, Inc. www.gosnold.org

2. Family engagement has been stated as a fundamental element of treatment (Etheridge and Hubbard, 2000), noted to predict improved retention in treatment (Liddell, 2004) and can lead to better outcomes (Coppello et al., 2005).

3. FAMILY Addicted Individual Treatment Systems Clinical Interventions A three-fold look at issues of family engagement

4. Goals: Thanks to Dave • What is it like to be a family member coming into treatment systems? • What are the problems families bring to to us (if we ask?) • What ways can we meet the needs of families?

5. When family is marginal: talk through, walk-through First Contact: no families allowed to call Pre admission: N/A. First meeting, intake assessment: psychosocial assessments embedded bias (family as perps!) Orientation: “Our rules, our way.” Embedded bias: Family as rule-breaking enablers. The treatment episode: continuum of non-contact. Family as disruptors of healing. Problem people who are NEEDY! Discharge, continuing care: and now, back to the family

6. First contact/admission stories from walk-through • The prospective client is the only one who can call. • Agencies gathered little information from the family members about the client. Information for family members was usually not provided. • Family members were often treated with suspicion, discouraged from engagement, or dismissed from consideration. • The role-playing family member wasfrequently ignored or asked to wait.

7. The things we do and don’t do • Other than children who were enrolled in the programs, family members were unwelcome. • Visitation was allowed, but was usually scheduled on weekends when core staff members were not available. • Family members of men more were likely to access services than women. Stigma • Unmarried partners less likely to be welcome. • Many staff changes make it difficult to implement hand offs of new clients, and to inform family members who the woman’s counselor will be.

8. And what is family anyway? “For practical purposes, family can be defined according to the individual’s closest emotional connections.” (SAMHSA,TIP 39, P.3).

9. Looking at the discrepancies between what we say and what we do: 3C’s • Cause: Many assessments look for genetic and environmental contributions to the individual’s addictions • Control “family prevented person from getting help” (purposefully because they were TOOO CO-DEPENDENT & they didn’t go to Alanon. • Cure—if family had not enabled—the person would have been cured by our treatment • Family might have contributed to abuse, neglect, violence—our population more likely to have add-ons.

10. When family is engaged: a NIATx view of engagement

11. Lessons from CSAT’s PPW programs—another NIATx project 1. Pre-admission and first night: Walden House, California asks woman to identify family to attend a first dinner. The Village South Miami offers family a tour of the program. Others offer FAQ sheets and even phone numbers and names to contact counselors!

12. Orientation for family Consider adding in time for questions from families. Develop Frequently Asked Questions materials from family member questions. Consider opportunity for confidential information sharing. Consider understanding what family needs from us as well as what we need from family!

13. Learn from families • SSTARBIRTH used informal focus groups at dinner to solicit input from family members on how to increase family participation. They changed visiting times in order to increase engagement. • Consider adding a family alumni group

14. Visitation may be good for treatment • PROTOTYPES holds potluck dinners that helped increase contacts from 81 to 115 • WEKU quadrupled the participation in family night and has added a mother/daughter tea • Family Works of Omaha offers a barbeque family picnic. • Waldenhouse has a family outreach event approximately once per month, such as an outing at a park.

15. Arkansas goes karaoke(percent families attending)

16. Prototypes California • COMMUNITY IMPACT: • Reduced costs of foster care • Reduced recidivism in treatment • Reduced costs of welfare through vocational linkages • Increased family support through community based linkages • PROGRAM IMPACT: • Increased retention • Help broader program to become more family focused • Use “changes” as pilot studies for program enhancement • Increased family bonding

17. What’s it like to be a family member? Worry, sleepless nights. Your disease controls my life and affects everyone in my life. Mistrust, hurt, anger, love, hate, hope, discourage, guilt, understanding, disbelief.

18. Listening to stories and concerns: Toast at 3:00 a.m. • Afraid he is going to die. Afraid he will kill someone. Not knowing what he is going to do. • The lying hurt. • I feel like I am watching you die a very slow death. • It was heartbreaking to watch you deteriorate physically, mentally, spiritually right in front of my eyes.

19. LANGUAGE: 4 C’S Reducing shame and stigma for families: • Cause – yes, families think they caused it. • Control – families think they can control it, by vigilance • Cure – families want to cure it by doing the right thing.

20. With the disease To change the oil or not to change the oil. To delete the phone numbers on cell or not. With the recovery Decisions, 4. Collaboration a skill

21. Learning from and with families4-session exercise • A time line: what the family has witnessed. (clinical tool and an empathy) Process: how many years does this time line cover, and how long have you known it’s a problem

22. Questions to process time line with families • How long ago did the problems start? • When did you know there was a problem? • Experience: most families have a great store of data regarding the progression and path of the addiction.

23. ROLES QUIZ: no more language of blame: the end of enablers in our life time

24. Moving company Tow truck Answering machine Doormat Baby sitter Laundromat Banker Judge, probation officer Personal shopper Personal credit company Night watchman “It” peace keeper detective counselor

25. Stages of change for families • Parallel process demonstration try to change something. • Renaming for access the YEAH BUT STAGE ContemplationStage

26. Communication: See Think Feel (and yes and no exercises) • What do you observe? I see you go to meetings every night • What does it make you think? It makes me think that you are taking your recovery seriously and that you are really making an effort • How does it make you feel? And it makes me feel proud and hopeful.

27. Skills development and processing with families 1. Parallel Process Demonstration: working with signs and symptoms Ask: When the addict is doing that, what are you doing? What are your signs and symptoms

28. AI: 1. Triggers are: 2. Situations that are unsafe for me in early recovery. 3. If I behave this way = relapse help me by 4. If I relapse do this 5. My aftercare plan and responsibilities are: Family: 1. What triggers your fear of a relapse? 2. What situations would be safer for you to avoid? 3. Seeing AI’s behaviors 4. If a relapse, then I will: 5. My responsibilities for my health. Recovery work sheets and recovery agreement

29. The down side of families When they get the idea that there is help they want MORE: They don’t leave the basement. Families don’t have crises on your schedule. They always want to jam an intervention into 3 hours yesterday.

30. Gosnold’s Spectrum of Services Open Availability: GRO phone Sunday Education Interventions Recovery Coaching Drop-in Support Community Forums, including intervention demo for community and hospitals. Gosnold at Cataumet: Weekly education; multi family group

31. 17 Months Gosnold Reaching Out: number of individualsand families served

32. Potential for collaboration • Advocacy • Broadening our definition on who is affected and making family a customer. • Compassion for the impact of addiction on lives of the affected.

33. Resources • SAMHSA: “Family-Centered Treatment for Women with Substance Use Disorders—History, Key Elements, and Challenges”, 2007 • Invitational Intervention, Judith Landau and James Garrett, 2006: Linking Human Resources • ARISE training and consultation: www.linkinghumansystems.com • Monica McGoldrick et al. Genograms: Assessment and Intervention, W.W. Norton, 2007 • Monica McGoldrick, You Can Go Home Again: Reconnecting with Your Family, W.W. Norton, New York, 1995 • CSAT, Substance Abuse Treatment and Family Therapy, TIP 39 • And of course: www.NACOA.org; Timmen Cermark, Salvatore Minuchin, Virginia Satir, Claudia Black, Sharon Wegscheider-Cruse, and a host of others who have informed treatment approaches and understanding the complexities of families affected by substance use disorders.