Addictive behaviours and the family: Impacts, models and interventions

Transcription

1 Addictive behaviours and the family: Impacts, models and interventions Professor Alex Copello, PhD School of Psychology, The University of Birmingham, UK ICTAB 2015 Odense, Denmark

2 Acknowledgements

3 AFINet Aims Our Aims: Provide information Evidencebased practice FM-centred research Influence policy Raise awareness of FMs & FM models

4 Plan Addiction in context Families extent and impacts Evidence based family interventions SSCS model - Helping family members in their own right Friends Social support and outcomes - interventions Implementation Working with families and social networks in other generic settings

5 Addiction in Context

6 The particle vs the social paradigm..peter Adams (2008) Fragmented Intimacy: addiction in a social world, New York, Springer. People as particles or people as relationships.

7 Individual vs. social view of addictions

8 Social Context Family and Friends Some Similarities... Some differences...

9 SOCIAL NETWORKS

10 UKATT Research Team (Principal Investigators) Alex Copello Christine Godfrey Nick Heather Ray Hodgson Jim Orford Duncan Raistrick Ian Russell Gillian Tober West Midlands York Newcastle South Wales Birmingham Leeds York/Bangor Leeds

11 Participants Participants entering the UKATT trial were asked about the people they had spent most time with over the previous three months (aged at least 12 years old). They named these important people and described each of them using demographic and drinking-related characteristics. Overall 4677 important people were named. All 740 participants could name at least 1 important person; the highest number named was 12. Participants could most frequently name 10 people, and the mean number named was 6.5 (standard deviation 3.6). This graph shows numbers of important people named by participants: Important people Participants then decided which of these people were the four most important and listed them in order.

12 frequency The four most important people: how were they related to the drinkers? This graph shows how the participants were related to their four most important people. Frequencies of relationship type are shown for the 1st, 2nd, 3rd and 4th most important people to the drinker significant other family friend other important person no. The majority of people entering alcohol treatment named their partner as the most important person, although family members were also a popular choice. Very few drinkers named their partner as least important person of the four. Members of close family were predominantly named as second or third most important, and friends were commonly named as third or fourth.

13 Who were the most important family members? Relationships of important people to focal drinkers could be further broken down into relationships of family members. This graph shows percentages of type of family member (from overall relationship) who were named as each important person: children parent sibling other/family 0 1s t 2nd 3rd 4th Parents were most frequently named as first and second most important, children as second or third most important, and siblings as third most important. Other family members were more likely to be named as the fourth than as the most important person.

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15 SAMPLE 118 participants 93 (79%) men Mean age = 35.5 (20-60) Ethnicity: 73% white-british 14% south Asian 4% black 8% mixed Drug use in past 28 days: Heroin 56% (md 7 days) Cocaine 34% (md 6 days) BZ 8% Cannabis 39% Alcohol 48% 15% had injected

16 Day, Copello, Chohan et al., European Addiction Research Opiate Substitution Treatment in the UK 118 participants identified a total of 820 network members Mean network size was 6.9. Of this group, 47 (6%) were sexual partners 378 (46%) immediate family members 97 (12%) extended family members 189 (23%) friends 16 (2%) colleagues from work 51 (6%) treatment professionals or members of self-help groups 42 (5%) others So, two thirds of the social network was made up of family members

17 'We are always in some form of contact': friendships among homeless drug and alcohol users living in hostels - J Neale, C Brown - Health & social care in the community, 2015 Homeless drug and alcohol users have small friendship networks that are often undermined by arguments, geographical mobility and imprisonment. Homeless drug and alcohol users desire culturally normative friendships, underpinned by routine and regular contact. Information and communication technologies are central to the friendships of many homeless drug and alcohol users, keeping them connected to sources of social support and recovery capital outside homelessness and substance-using worlds.

18 Most people entering treatment for alcohol and or drug problems in the UK are not isolated or lack potential sources of social support Also suggests that a number of people can potentially be affected by the impacts of the problem and resulting harms to others Despite some apparent differences between the two treatment groups, such as the higher number of partners proportionately reported by the alcohol treatment sample, the largest composition of the networks appears to comprise family members

19 Beyond treatment samples, wider estimates of the extent of affected family members

20 How large is the (impact on family) problem? It is estimated that there are approximately 15 million people with drug use disorders globally and 76 million with alcohol use disorders (Obot, 2005). A cautious estimate of just one person seriously affected in each case suggests a minimum of 91 million affected family members Most people would use a greater multiplier and produce a higher figure

21 What is the extent of the problem? Drug treatment population 50,373 partners 55,012 parents 35,208 other General population 573,671 partners 610,970 parents 259,133 other Total = 140,593 Total =1,443,774 Key findings from UK DPC study about adult family members of drug misusers. What about alcohol misuse? Up to 1 million children are affected by parental drug misuse & up to 3.5 million by parental alcohol misuse (Manning et al., 2009). It is estimated that the impact of drug misuse on the family costs the UK 1.8 billion but also brings a resource saving to the NHS of 747 million through the care provided.

22 In 2008 the Harm to Others survey was conducted with 2600 people in Australia (Laslett et al. 2011) and 3068 in New Zealand (Casswell, You and Huckle 2011). Just over a quarter (28%) of Australian adults reported being negatively affected by the drinking of someone they knew. Younger respondents were more likely to report that they had been affected, and compared to males; females were almost twice as likely. Seven percent of respondents reported living with a problematic drinker in the past year; often their partner or a family member. In New Zealand however this figure was considerably higher, with 1 in 4 reporting that the heavy drinker was part of their household (Casswell, You and Huckle 2011).

23 Percentages (and CIs) of respondents negatively affected in last 12 months by drinkers in various relationships Laslett, Room, Ferris, Wilkinson, Livingston, & Mugavin (2011). Addiction, 106,

24 We know it is a highly prevalent problem.

25 Stresses and Strains

26 THE UNIQUE SET OF STRESSFUL CIRCUMSTANCES FOR FAMILIES COPING WITH ADDICTION Has the nature of severe stress, threat and abuse Involves multiple sources of threat to self and family, including emotional, social, financial, health and safety Can have significant impact on children Worry for that family member is a prominent feature There are influences in the form of individual people and societal attitudes that encourage the troubling behaviour Attempting to cope creates difficult dilemmas, and there is no guidance on the subject Social support for the family is needed but tends to fail Professionals who might help are often at best badly informed and at worst critical

27 P.Care 1 P.Care 2 UK Mexico Wives Psych Control Symptoms of Ill Health Family members Family members; psychiatric out-pts. and community controls

28 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 other psychological problems Ray et al (2007) The excess medical cost Medical Care

29 Population estimates of contact with law enforcement services and health-related services due to others drinking, 2008 (weighted data) Mugavin, Livingston, & Laslett (2014). Drug and Alcohol Review, 33,

30 Reduced medical costs in family members of individuals who are abstinent after addiction treatment Weisner, Parthasarathy, Moor, & Mertens (2010). Addiction, 105,

31 Embarrassment when illness strikes a close relative: A multi-site study Ahmedani et al., 2013 Psychological Medicine Investigated social stigma: family members embarrassment by relative s mental health or alcohol or drug problem. 16 sites across various countries with a combined n= Looked at burden and the experience of embarrassment

32 Embarrassment when illness strikes a close relative: A multi-site study Family members experienced embarrassment: 24.9% of FMs experiencing General Medical Conditions 49.5 % of FMs of Alcohol and Drug Conditions 36.6 % of FMs of both conditions above combined Also found that embarrassment was not a function of burden Implications for early intervention and treatment entry delay

33 Interventions involving families and wider networks

34 A narrow individual focus on treatment and help fails to consider some facts: That living with a significant alcohol or drug problem is a highly stressful experience That the stress experienced leads to physical and psychological symptoms for family members That family members use generic and primary care services to seek help That family members provide significant care That family members can improve outcomes for the substance user

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

36 An Overview of ways of involving family members (FMs) Working With FMs to engage relative in treatment Community reinforcement & family training Unilateral Family therapy Cooperative counselling Pressure to change Johnson Intervention Joint involvement of FM and their relatives in treatment Conjoint family group therapy Alcohol behavioural couples therapy Family therapy Network therapy Social behaviour & network therapy (SBNT) Responding to Needs of FM in their own rights Group treatment Al-Anon / Families Anonymous Supportive stress management counselling Parent coping skills training 5-Step Method

37 Despite the available evidence and potential gain, shifting the emphasis from individualised treatment approaches to those focused on the substance user s family and social environment presents a number of significant challenges (Copello, 2006)

38 Family members in their own right SSCS model & 5 Step Method

39 Despite the recognition of carers needs and the growth of carer organisations, however, there is a rather limited evidence base assessing the impact on carers and families of people who misuse drugs and on interventions intended to support them, and even less attention given to the needs of families and carers in their own right. National Institute of Clinical Excellence (NICE) 2008.

40 Relative s addiction problem Stress on family member Social support for family member Understanding Ways the family member copes Family member strain The stress-strain-coping-support model 40

41 Families in three contrasting cultures

42 Relative's addiction problem Variations by problem severity; family disharmony; living arrangements; material resources. Stress on family member Worried for the relative Affected by the relative Informal (kin/non-kin) Information and understanding Variations by length of time coping; relationship to the relative; culture Professional (as available) Social support for family member Ways family member copes Putting up Family strain or resilience Standing up Withdrawing Own demoralisation and ill-health Child and family disturbance and ill-health

43 The 5-Step Method Derives from the Stress Strain Coping Support (SSCS) model and what family members have told us in a number of research studies. The 5-Steps are: 1. Let the family member tell their story. 2. Provide information. 3. Discuss ways of responding. 4. Explore sources of support. 5. Arrange further help if needed.

44 one two three four five The 5 steps Listen, reassure and explore concerns Provide relevant, specific and targeted information Explore coping responses Explore and enhance social support Discuss and explore further needs 44

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46 How does the 5-Step Method help FMs? Several research studies in the UK and Italy, including one randomised controlled trial. Research in primary care, and also statutory and non-statutory drug and alcohol services. Mixed method research, involving both questionnaires and interview data. Data from over 250 family members. Pilot studies with groups, and of online support.

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48 Some Findings FMs mainly female and mothers or partners. Users tend to be male and alcohol or drug (heroin) misusers. FMs have been living with the situation for an average of 8-10 years, feel generally isolated with low levels of support and previous negative experiences of help-seeking.

49 Some findings For family members: A positive and significant change in coping behaviour. Reduction in symptoms (physical and psychological). Lessening of the impact of the problem. For practitioners: Confidence in working with family members. Awareness of the importance of working with family members.

50 Examples of how the 5-Step Method can influence coping responses Increased focus on own life and needs (gaining independence). Increased assertiveness over the misuse (resisting and being assertive). Taking a calmer approach towards the misusing relative (reduced emotional confronting). Increased awareness of the relative s misuse problem and its effects on family members (cognitive change).

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53 Wider social networks including friends supporting substance users

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55 Social Networks and Addiction Problems Structure of networks Problem recognition and help-seeking Treatment outcome After treatment

56 Social Support and Outcomes General social support Alcohol-specific social support Drinking behaviour of the social network members All unique predictors of alcohol treatment outcomes

57 The addition of just one alcohol abstinent person to the social network may increase the likelihood of abstinence by 27% (Litt et al., 2007).

58 How did they feel about the focal drinker getting alcohol treatment? Important people rarely opposed treatment. The most important person was particularly supportive (78.89% supported treatment), and even fourth most important people were predominantly supportive (53.18%). Just over 10% of all important people felt neutral towards treatment. The third and fourth most important people were more likely than the first/second not to know about treatment. This graph shows the percentages of important people (1 st, 2 nd, 3 rd and 4 th who fell into each category: opposes treatment mixed neutral supports but prefers alternative supports treament in this program doesn't know 1st 2nd 3rd 4th

59 The 4 most important people who have daily contact with the focal drinker 500 Diagramtitel heavy drinkers Non-heavy drinkers st IP 2nd IP 3rd IP 4th IP

60 Overall... Participants recruited to UKATT had people in their social networks Based on participants reports, most had people in their networks that did not have alcohol problems Most had people in their networks that were supportive of the focal client s treatment

61 Social Behaviour and Network Therapy (SBNT) Built upon the premise that social network support for change is central to the resolution of addictive behaviour Integrates effective strategies from other treatment approaches Initially targeted at alcohol problems UK Alcohol Treatment Trial (UKATT)

62 SBNT: Key Principles Always think network. Draw a network diagram. Invite members of the network. Strengthen the network. Discuss themes of: communication, coping, information, joint activities. Work with any part of the network. Plan for the future.

63 SBNT content Core topics Communication. Coping. Enhancing social support networks. Developing a networkbased relapse management plan. Elective topics Basic education on drugs/alcohol. Increasing pleasant activities. Employment. Minimising support for drug/alcohol use.

64 SBNT adapted for use with primary opiate users 20 therapists from Birmingham CDTs trained to deliver SBNT, supported by a treatment manual and a two-day workshop followed by video supervision 12 therapists delivered SBNT to 24 patients, and 3-month outcomes showed reductions in drug use and improved family and social relationships

65 How about service provision and delivery of evidence based family and network interventions?

66 UKDPC research on adult family /carers Phase 2: Aims To describe the extent and nature of support provision for adult family members / carers of people experiencing drug problems to highlight gaps and good practice to help improve provision. Components: Review of policy & guidance in the UK Web survey of service providers in the UK In-depth study: 20 DAT areas in England & 8 ADPs in Scotland Research team: Alex Copello, Lorna Templeton, Gagandeep Chohan & Trevor McCarthy

67 Current Service Provision in the UK Patchy provision of family-focused drug and alcohol intervention services across the UK Often based on poor or insecure funding. A focus on treatment for the substance misuser mostly. Copello et al (2006) the responsibility for increasing implementation for family-based services lies not only with service providers but also with policy makers and commissioners.

68 Developing Family Focused Practice

69 Overall proportion of family-focused practice increases after targeted program of work within an organisation (from Claire Hampson s PhD work) % family-focused practice *^ * Baseline (117/611) Training & Supervision period (108/410) Post-intervention (257/765) *Significantly greater than baseline. ^Significantly greater than training period.

70 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 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 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 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 Perceiving and experiencing challenges and difficulties We ve had it rammed down our throats careful of the confidentiality, careful not to give anything away Individualistic practices remain A one-to-one can be quite precious and that s my preference to working Limited family-focused practice within outside organisations GPs only refer drinkers, they don t think about the affected family members INTERNAL EXTERNAL

71 Responding to families in other settings

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73 Increasing access to Psychological Therapies (IAPT) services sit within primary care and aim to ensure that psychological interventions are offered as frontline to those with mild to severe presentations of depression and anxiety, alongside treatment as usual by their General Practitioner. The sample of 100 clients was made up of 40 men and 60 women. The mean age of the sample was 38.5 years The first question asked of participants was: At the time of entering the IAPT service did you/do you have a family member whose level of alcohol and/or drug use concerns you? (Yes, No). Twenty-two responded with a Yes

74 Thirteen participants reported having a family member whose alcohol use was of concern (59 %), five drugs (23%) and four both (18%). There was a significant difference between the mean depression scores of the 22 positive cases (19.2, s.d. 4.0) compared that for the remaining 78 clients (15.8, s.d. 6.1) (p < 0.05), but no significant differences in anxiety scores. This pilot study provides some indication that a large minority of IAPT clients may be seeking help partly because of substance misuse problems in the family suggesting the study deserves replication and extension.

75 Some tentative concluding thoughts Addiction is sufficiently stressful to cause pain and suffering to a very large but unaccounted number of adults and contributes to the global burden of adult ill-health The impact and cost of the care given by family members is significant. Alcohol and drug policies are increasingly recognising the needs of family members or how they can be involved in treatment. Specialist service delivery remains predominantly oriented towards the focal alcohol or drug client, although there is evidence of a wide range of interventions to support families, and some evidence that more services are becoming available. An effective response to the needs of family members has the potential to significantly reduce harm and health problems in this group and could be delivered in generic services Involving family members in supporting the treatment of the user can improve outcomes We need to develop flexible approaches, deal with implementation barriers and aim to understand better the mechanisms of change for both groups

76 Thank you for listening