Effectiveness of an Educational and Support Program for Family Members of a Substance Abuser

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1 The American Journal of Family Therapy, 40: , 2012 Copyright Taylor & Francis Group, LLC ISSN: print / online DOI: / Effectiveness of an Educational and Support Program for Family Members of a Substance Abuser AMANDA JEFFREY PLATTER Virginia Consortium Program in Clinical Psychology, Virginia Beach, Virginia, USA MICHELLE L. KELLEY Department of Psychology, Old Dominion University, Norfolk, Virginia, USA The present study examined changes in enabling and coping among 32 family members who attended a 6-week communitybased educational and support group designed for family members of substance abusers. Participants completed the Enabling Behaviors subscale of the Behavior Enabling Scale (Rotunda & Doman, 2001) and the 8 subscales from the Brief COPE Inventory (Carver, 1997) at pretreatment, posttreatment, and 30-day posttreatment follow-up. Participants reported significantly less enabling behavior from pretreatment to posttreatment and from pretreatment to 30- day follow-up, and significant improvements in active coping (i.e., Positive Reframing, Use of Instrumental Support, and Behavioral Disengagement), but no reduction in emotion-oriented coping. Although a loved one s substance abuse may have many effects on their family members, two of the most frequent challenges to these family members are enabling behaviors and coping. Enabling behaviors are actions that are meant to stabilize or reduce substance use but may inadvertently perpetuate a loved one s continued alcohol or drug alcohol abuse (Meyers & Wolfe, 2004). These include taking over responsibilities, accepting excuses, and covering up or minimizing alcohol- and drug-related incidents to other family members, employers, and friends (Orford et al., 2007). Enabling behaviors are natural reactions to the stress created by the abuser s substance We would like to thank Nora Hamel and Dr. Jeffrey Sheldon at the participating community services board, and Gabrielle M. D Lima, Robert Milletich, and Matthew R. Pearson for their comments on an earlier version of this article. Address correspondence to Michelle L. Kelley, Department of Psychology, Old Dominion University, MGB Room 250, Norfolk, VA. mkelley@odu.edu 208

2 Effectivness of an Educational and Support Program 209 use (Rychtarik, Cartensen, Alford, Schlundt, & Scott, 1988), but can be unlearned in the context of education and support (Rotunda & Damon, 2001). Coping has been defined as the cognitive and behavioral efforts to master, reduce or tolerate the internal and/or external demands that are created by the stressful interaction (Muller & Spitz, 2003, p. 508). Folkman and Lazarus (1980) argued that individuals cope with a threat by active coping such as planning ahead, searching for information, and seeking social support, or emotion-focused coping which involves reducing the emotions associated with another s substance abuse (Carver, Scheier, Weintraub, & Kumari, 1989). The present study utilized a pre-post test design to examine enabling behaviors and coping among participants who attended a six session community-based psychosocial group for family members of substance abusers. It was hypothesized that enabling behaviors and emotion-oriented coping that may be counterproductive (e.g., Self blame, Denial, and Venting) would decrease from pretreatment to posttreatment and from pretreatment to 30-day posttreatment follow-up, and that active coping would increase from pretreatment to posttreatment and from pretreatment to posttreatment 30-day follow-up. METHOD Participants were 32 individuals (23 parents or stepparents, six partners, and three siblings) who attended the Friends and Family Program, a free, voluntary, one evening per week, six-week closed psychoeducational and support group. Most participants (n = 27) were White. Group sessions follow a structured manual and involve lectures, videos, and discussion (see Table 1). The Friends and Family program was based on work by Meyers and Wolfe (2004). The first half of each session had a psychoeducational focus (e.g., the effects of addiction on family members, how enabling behaviors may interfere with recovery); the latter half was designed to facilitate discussion. The program was facilitated by an experienced master s level individual with a background in education and counseling. Respondents completed the 10-item Enabling Behaviors subscale (e.g., I gave my family member or friend money to buy alcohol or drugs ) of the Behavioral Enabling Scale (BES; Rotunda & Doman, 2001). Participants also completed five subscales of the Brief COPE Inventory (Carver, 1997) that assess active coping (i.e., Positive Reframing, Use of Instrumental Support, Behavioral Disengagement, Active Coping, and Planning), and three subscales that assess Emotion-oriented coping (Denial, Venting, and Selfblame). The instructions for the Brief COPE Inventory subscales were modified so that participants were asked to indicate how much they used each of the coping techniques since that found out about their loved one s drug or

3 210 A. J. Platter and M. L. Kelley TABLE 1 Techniques Used in the Family and Friends Program Type of Techniques Examples Active Listening/Reflection Encouraging participants to suspend judgment and listen to the narratives of others Encouraging fully attending to the speaker Asking participants to reflect on how their stories compare Videotapes Presenting educational videos on the nature of enabling and asking participants to reflect on how the content applies to the their relationship with their substance abusing loved one Suggesting videos and television programs for participants to watch at home and share reflections at next group meeting Interpersonal Feedback Encouraging group members to speak spontaneously about their experiences and personal stories while also encouraging respectful criticism of other s enabling choices and coping behaviors Reading aloud literature related to enabling and coping to group members and sharing how the content applies to their personal experiences with a substance abusing loved one alcohol abuse. Two subscales, Venting and Active Coping, had poor reliability (αs <.63) and were not examined further. Higher scores denote more enabling/active/emotion-oriented coping. The study was approved by the Institutional Review Board at the authors university and the participating community services board. Participants provided written consent. Pretreatment assessment took place at the initial session; posttreatment data collection took place immediately after the final session. The 30-day posttreatment follow-up was completed by telephone or returned by mail. Participants were mailed a $10 dollar gift card at the end of the study. RESULTS Two participants had missing items on the Brief COPE Inventory and one participant had an incomplete BES; missing item scores were imputed with the subject s mean for the remaining items. Scores were then tested for linearity, skew, and kurtosis; no violations were observed. Results of repeated measures ANOVAs showed that enabling behavior significantly decreased from pretreatment to posttreatment and from pretreatment to 30-day posttreatment follow-up (see Table 2). Participants increased their use of Positive Reframing and Behavioral Disengagement strategies from pretreatment to posttreatment and from pretreatment to 30-day posttreatment follow-up, and participants reported higher Use of Instrumental Support from pretreatment to 30-day posttreatment follow-up.

4 Effectivness of an Educational and Support Program 211 TABLE 2 Means and Standard Deviations for Behavioral Enabling Scales and Brief COPE Inventory Subscale Scores at Pretreatment, Posttreatment, and 30-day Posttreatment Followup Pretreatment Posttreatment Follow-up Scale/Subscale M(SD) M (SD) M (SD) F η 2 BES (9.92) a (9.32) b (10.03) b COPE Positive Reframing (1.58) a (1.62) b (1.58) b Instrumental Support (1.68) a (1.73) ab (1.79) b Behavioral (1.54) a (1.34) a (1.86) b Disengagement Planning (1.63) a (1.79) a (1.79) a Self-blame (1.88) a (1.74) a (1.61) a Denial (1.79) a (1.80) a (1.73) a Note. BES = Behavioral Enabling Scale; COPE = BES = Brief Cope Inventory. Means with differing superscripts within rows are significantly different at p <.05 as determined by Tukey post-hoc tests. p <.05. p <.01. p <.001. DISCUSSION A key element of programs for family members of substance abusers is the emphasis on teaching how to recognize enabling behaviors and providing support in applying this knowledge to their interactions with the substance-abusing loved one (Meyers et al., 2002; Rotunda et al., 2004). As anticipated, participation in the program had a meaningful impact on the reducing enabling behaviors. Not only were enabling behaviors addressed in the psychoeducational information presented during the course, but also group members asked one another about enabling behaviors throughout the sessions, advised one another on how to reduce enabling behaviors, and discussed the negative long-term outcomes from continued enabling behaviors. The combination of education and support from other participants appears to reduce these enabling behaviors (e.g., Rotunda & Damon, 2001). Similar to results of previous research (Bernhard et al., 2006), the education and social support provided by this community program appears to have helped members develop ways of positively reframing or shifting their focus away from the stresses associated with addiction. Importantly, Orford et al. (2007) found that increased awareness of their family member s addiction and their ability to see positive alternatives to interact with their loved one s contributed to participants feelings of well-being and optimism. Moreover, reductions in enabling behaviors are associated with positive changes in family member s well-being and in decreases in their loved one s substance use (Miller, Meyers, & Hiller-Sturmhofel, 1999). Although instrumental support did not increase from pretreatment to posttreatment, participants reported being more likely to get advice or help from others at the 30-day posttreatment follow-up as compared to

5 212 A. J. Platter and M. L. Kelley pretreatment. After the program ended, participants may have recognized the importance of instrumental support and used the information that they learned in the sessions to seek additional instrumental support. Some forms of treatment strengthen over time because the program participants begin to apply what they have learned after the program ends (Zelvin, 2004). These results are important because families with an active substance-abusing family member are often isolated from external sources of support (Easley & Epstein, 1991). In situations in which the individual does not have control over a stressful event, distancing oneself is generally considered adaptive (e.g., Luszczynska, Gerstorf, Boehmer, Knoll, & Schwarzer, 2007). As such, the facilitator encouraged participants to let their substance-abusing loved one solve their problems independently. As expected, behavioral disengagement increased over time. These results support those of Orford et al. (2007) who observed similar trends in his qualitative examination of family members who had completed a psychoeducational intervention for loved ones of drug and alcohol abusers. More specifically, Orford et al. found that scores on Independence (i.e., focusing on own life/needs, distancing from the relative s problem drinking or drug taking) increased. The Independence dimension assessed by Orford et al. appears similar to the behavioral disengagement items assessed in the present study. Specifically, both assess distancing emotionally from the loved one s substance abuse problem and may be an adaptive response or form of self-care. The present study has a number of methodological limitations including a small sample, limited generalizability in that most participants were parents, and low internal consistency for two of the Brief COPE Inventory subscales (likely due to two items per scale). Although a longer coping instrument may have yielded higher internal consistency, it was necessary to work the assessment into the format of the program to ensure that all participants completed the measures immediately before and after the program ended. Despite these limitations, results indicate that a brief psychoeducational and support group shows short-term benefits for reducing behavioral enabling and increasing active coping among family members of substance users. Although the program appeared to have benefits for active coping, additional forms of support may be necessary to help family members with reducing emotion-oriented coping. REFERENCES Bernhard, B., Schaub, A., Kummler, P., Dittmann, S., Severus, E., Seemuller, F.,... Grunze, H. (2006). Impact of cognitive-psychoeducational interventions in bipolar patients and their relatives. European Psychiatry, 21,

6 Effectivness of an Educational and Support Program 213 Carver, C. S. (1997). You want to measure coping but your protocol s too long: Consider the Brief COPE. International Journal of Behavioral Medicine, 4, Carver, C. S., Scheier, M. F., Weintraub, J. K., & Kumari, F. (1989). Assessing coping strategies: A theoretically based approach. Journal of Personality & Social Psychology, 56, Easley, M. J., & Epstein, N. (1991). Coping with stress in a family with an alcoholic parent. Family Relations, 40, Folkman, S., & Lazarus, R. (1980). An analysis of coping in middle-aged community sample. Journal of Health and Social Behavior, 21, Luszczynska, A., Gerstorf, D., Boehmer, S., Knoll, N., & Schwarzer, R. (2007). Patient s coping profiles and partners support provision. Psychology & Health, 22, Meyers, R. J., Miller, W. R., Smith, J. E., & Tonigan, J. S. (2002). A randomized trial of two methods for engaging treatment-refusing drug users through concerned significant others. Journal of Consulting and Clinical Psychology, 70, Meyers, R. J., & Wolfe, B. L. (2004). Get your loved one sober: Alternatives to nagging, pleading and threatening. Center City, MN: Hazelden Publishing & Educations Services. Miller, W. R., Meyers, R. J., & Hiller-Sturmhofel, S. (1999). The community reinforcement approach. Alcohol Research & Health, 23, Muller, L., & Spitz, E. (2003). Multidimensional assessment of coping: Validation of the Brief COPE among French Population. Encephale, 29, Orford, J., Templeton, L., Patel, A., Copello, A., & Velleman, R. (2007). The 5-step family intervention in primary care: Strengths and limitations according to family members. Drugs: Education, Prevention and Policy, 14, Rotunda, R. J., & Doman, K. (2001). Partner enabling of substance use disorders: Critical review and future directions. The American Journal of Family Therapy, 29, Rotunda, R. J., West, L., & O Farrell, T. J. (2004). Enabling behavior in a clinical sample of alcohol dependent clients and their partners. Journal of Substance Abuse Treatment, 26, Rychtarik, R. G., Carstensen, L., Alford, G. S., Schlundt, D. G., & Scott, W. O. (1988). Situational assessment of alcohol-related coping skills in wives of alcoholics. Psychology of Addictive Behavior, 2, Zelvin, E. (2004). Treating the partners of substance abusers. In S. Straussner (Ed.), Clinical work with substance-abusing clients (2nd ed., pp ). New York, NY: Guilford Press.

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