Families and addiction:Stress, symptoms and coping responses Professor Alex Copello Birmingham and Solihull Mental Health Foundation Trust and University of Birmingham, UK Families First – DDN, Adfam Conference Birmingham, Holiday Inn, 15th November 2012
…it ought to be both surprising and shocking that there has been so little in the way of a co- ordinated response to families living with the drug problem of their son or daughter, brother or sister. Marina Barnard Drug Addiction and Families 2007, p. 51
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)
A narrow individual focus on treatment and help fails to consider some well proven 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 (e.g. UKDPC)• That family members can improve outcomes for the substance user
BARRIERS... to recognition andto accessing formal and informal support
Why work with families?1. ‘Carer burden’ is extremely high and families need support in their own right• Costs are financial, social, psychological, physical and relational• Reciprocity of well-being• Families indirectly influence relatives’ using behaviour• We need to consider the whole system of the family, not just the individual when thinking Recovery.
Why work with families?2. Improved client treatment outcomes• Increases client entry into treatment• Improves engagement and retention of client in treatment• Improves substance use outcomes for clients• Reduces relapse• Families play crucial role in facilitating recovery
The four most important people: how werethey related to the drinkers?This graph shows how the participants were related to their four mostimportant people. Frequencies of relationship type are shown for the 1st, 2nd,3rd and 4th most important people to the drinker. 500 400 significant other frequency 300 family 200 friend 100 other 0 1 2 3 4 im portant person no.The majority of people entering alcohol treatment named their partner as themost 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 mostimportant, and friends were commonly named as third or fourth.
How large is the 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 membersMost people would use a greater multiplier and produce a higher figure
What is the extent of the problem? • Key findings from UK DPC study about adult family members ofDrug treatment General drug misusers. population population • What about alcohol misuse? • Up to 1 million children are affected by parental drug misuse50,373 partners 573,671 partners & up to 3.5 million by parental55,012 parents 610,970 parents alcohol misuse (Manning et al.,35,208 ‘other’ 259,133 ‘other’ 2009). • It is estimated that the impact of drug misuse on the family costs the UK £1.8 billion but alsoTotal = 140,593 Total =1,443,774 brings a resource saving to the NHS of £747 million through the care provided.
An International Picture• We have spoken directly to family members in: – England – Mexico City – Australia (Aboriginal communities) – Italy• What we have been told suggests that the impact of substance misuse on the family is remarkably similar all over the world.• Yet, particular elements of this experience can differ or be more prominent according to culture and social context.• This experience seems to be similar to people who live with other traumas.
Main Modifiers of the Core Family Member Experience Family Material FM female circumstances or male Relationship Traditional vs THE CORE to misusing Modern family EXPERIENCE relative roles Is modified by Substances use Culture: pattern individual, familial or communal Licit or illicit: traditional or recently introduced
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
Symptoms of Ill HealthFamily Family members; psychiatric out-pts. andmembers community controls 35 30 25 20 15 10 5 0 UK Wives Control Mexico P.Care P.Care Psych 1 2
Ray et al (2007)Compared family members of people with substance misuse problems withfamily 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 commonlydepression and other psychological problemsRay et al (2007) The excess medical cost… Medical Care
Three Common ways of responding ‘Putting up with it’ ‘Standing up to it’‘Withdrawing/Independence’
Practice► Some very good examples of services forfamily members but provision is patchy► Implementation of evidence basedpractice is low► Potential to improve availability andresponse to families
We know that family members have two related needs:To receive advice and support on their own right To be supportive of the relative’s treatment and involved if useful
“Being there” “Give advice” “Being a strength” “Day to day”“Continuity of support” “Your time” “Understanding” “Challenges”
5-Step Method• 1 – Listen, reassure and explore concerns• 2 - Give relevant targeted information (eg substances, treatment, support)• 3 - Explore coping responses – ‘engaged’, ‘tolerant’, ‘withdrawn’• 4 – Discuss social support – map• 5 – Discuss further support needs
TRANSFORMATIONS DESCRIBED BY FAMILY MEMBERS RECEIVING 5-STEPS IN PRIMARY CARE • 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)
Key message:A little support can have wide positive consequences
But most important:Seeing family members as partners in the challengingtask of helping people change addictive behaviours
UKDPC research on adult family /carersPhase 2: 2011-12Aims•To describe the extent and nature of support provision for adultfamily members / carers of people experiencing drug problems tohighlight 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 ScotlandResearch team: Alex Copello, Lorna Templeton, Gagandeep Chohan &Trevor McCarthy 2
Policy review findings [Note: Unpublished – please do not quote without permission]• Increased level of recognition of families in policy & guidanceBUT• ‘Families’ generally = children of substance-using parents• Little consideration of sub-groups of adult family members & their varying needs• More focus on involvement in treatment than help in own right• Lack of detail on what needs to be provided• Little consideration of monitoring quality or extent of provision• Need more recognition in strategies in related policy areas (eg criminal justice; DV). 3
Web survey findings [Note: Unpublished – please do not quote without permission]Characteristics of services•253 services from across the UK (70% non-statutory) 145 - England 71 - Scotland 22 - N Ireland 14 - Wales•Type of service 58% = Part of service for substance misusers 24% = Service solely for adult family members 10% = Part of generic carers service 8% = Other•Who worked with 89% = Drugs and alcohol59% = Families alongside drug users 11% = Drugs only 41% = Adult family member only 3
Web survey findings [Note: Unpublished – please do not quote without permission]Support to family members on their own Counselling 48% Bereavement 29% Co-dependency-based 22% 5-step method 9% 12-step support 7% CRAFT 1% PACT (1) Family therapy (1) 3
Web survey findings [Note: Unpublished – please do not quote without permission]Support for family members and drug users together 3
Areas for action• Improve needs assessment – different groups; – different needs; and – basic prevalence.• Develop targets and outcome assessment – to enhance provision; and – demonstrate value and build evidence base.• Promote the evidence – for what is needed; and – what works.• Workforce development - specialist and generic. 3
Concluding thoughts: a case of global public health neglect?• A significant public health problem.• 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.• 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