Family interventions for drug. Family interventions for drug. best practice?

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1 Family interventions for drug Family interventions for drug and alcohol misuse: Is there a best practice? Prof Alex Copello Consultant Clinical Psychologist Addiction Services Birmingham and Solihull Mental Health Foundation NHS Trust & Professor of Addiction Research The University of Birmingham a.g.copello@bham.ac.uk Presented at: HIDDEN HARM: Families, drugs and alcohol, challenges es and opportunities to develop the team around the child. The Royal College of Physicians, London, 18 th June 2009.

2 Addiction and the Family Addiction and the Family Plan Acknowledgements Why families matter What are family members needs? What do we know from research into family interventions? On the basis of the evidence, what may best practice look like? Implementation?? Some conclusions

3 ADDICTION AND THE FAMILY (ADF) GROUP ADDICTION AND THE FAMILY (ADF) GROUP The University of Birmingham/Birmingham and Solihull Mental Health NHS Trust Substance Misuse Service Jim Orford Akan Ibanga Alex Copello The University of Bath Mental Health R&D Unit/Avon & Wiltshire Mental Health Partnership NHS Trust Lorna Templeton Richard Velleman.and numerous other colleagues who have been part of this group over the years both in the UK and other countries.

4 During the past 3 decades, there has been increased recognition from researchers of the key role that families can play in substance misuse treatment, in terms of: preventing and/or influencing the course of the substance misuse problem improving substance-related outcomes for the user helping to reduce the negative effects of substance misuse problems on other family members. [Copello, Templeton and Velleman,, 2006]

5 RESEARCH POLICY PRACTICE

6 What do we know from What do we know from research?

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

8 Ray et al (2007) 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 Comparison group n = 141,722 n = 45,677 (male/female 46/54%) n = 141,722 (male/female 46/54%) More likely to be diagnosed with medical conditions most commonly depression and substance abuse Ray et al (2007) The excess medical cost Medical Care

9 We know that family members have two related needs: To receive advice and support on To receive advice and support on their own right To be supportive of the relative s treatment and involved if useful

10 Family Interventions Family Interventions

11 Family Interventions: Three Family Interventions: Three Broad Categories interventions that work with family members to promote the entry and engagement of drug and/or alcohol users into treatment the joint involvement of family members and the relatives using drugs and/or alcohol in the treatment of the user interventions aimed to respond to the needs of family members affected by drug and alcohol problems in their own right [Copello, Velleman and Templeton, 2005]

12 TREATMENTS INVOLVING FAMILY MEMBERS (FMs ( FMs) Working With FMs to engage relative in treatment Family intervention intervention Community reinforcement & family training Unilateral Family therapy Cooperative counselling Pressure to change Joint involvement of FM and their relatives in treatment Conjoint family group therapy Behavioural couples therapy Family therapy Network therapy Social behaviour & network therapy Responding to Needs of FM in their own rights Concurrent group treatment Al Al-Anon Anon Families Anonymous Supportive stress management counselling Parent coping skills training 5 - step intervention

13 What can we learn form the most recent research studies? Copello, A., Templeton, L. and Velleman,, R. (2006) Family Intervention for drug and alcohol misuse: Is there a best practice? Current Opinion in Psychiatry, 19,

14 Some examples: 5-step brief intervention for family members Behavioural couple therapy Social behaviour and network therapy

15 Copello, Templeton, Orford, Velleman et al. (5-STEPS) family member focused 1. Listen non-judgementally 2. Provide information 3. Discuss ways of responding 4. Explore sources of support 3. Arrange further help if needed

16 Step Intervention: Changes in symptoms and coping behaviour Copello, Templeton, Orford, Velleman et al., (2009) Addiction Symptoms Coping Full Int Brief Int Feasibility 0 Full Int Brief Int Feasibility Baseline 3 month fup 12 month fup Baseline 3 month f.up 12 month f.up

17 Ideas Behind Behavioural Couples Ideas Behind Behavioural Couples Therapy (BCT) To eliminate abusive drinking and drug use To engage the family s s support for the patient s s efforts to change To change couple and family interaction patterns Stable relationship Stable abstinence

18 Social Behaviour and Network Therapy

19 Conclusions from the most recent studies The recent literature strengthens the evidence-base for family and social network interventions in alcohol and drug treatment and confirm the conclusions from previous reviews. The recent focus has broadened to include interventions aimed at moderation rather than abstinence and the inclusion of the wider social network consisting of a range of concerned family members and friends as well as partners. Sample sizes have improved and pragmatic designs implemented in routine treatment settings are a welcome development in this area. More published studies are focused on alcohol treatment as compared to illicit drugs, and the literature remains fragmented, with different groups using different measures, making comparisons across studies complex.

20 Is there enough evidence to propose a best practice? A number of approaches have enough evidence to merit implementation in routine practice e.g. Behavioural Couples Therapy is an examples with evidence suggesting efficacy if implemented according to clear manualised guidelines and robust training and supervision. Interventions focused on wider social networks are beginning to accumulate research evidence and hold promise for the future. There is now strong evidence that family members are negatively affected by a relative s substance misuse, and good evidence is emerging that these family members benefit from therapeutic interventions, either as part of an intervention involving their misusing relative, or independently of this.

21 Is there enough evidence to propose a best practice? Best practice is not only related to interventions. The evidence strongly supports the need to assess partner relationships when people enter treatment, a practice that is not widespread within treatment services There is long-standing evidence that the nature and quality of spousal relationships has a significant impact on treatment outcomes The real challenge, however, is posed by the evidence that shows very low levels of implementation of these evidencebased family approaches in routine practice This problem of the lack of implementation of the evidence-base into routine practice, however, is not restricted to family approaches.

22 Is there enough evidence to propose a best practice? Because several approaches have potential, best practice, in services should include: a) routine assessment of the strengths and needs of substance misusers current familial and social networks b) implementation of one or more of the range of evidence-based approaches which impact either on the substance user in their familial/social context, or on the affected family members.

23 What happens in What happens in practice?

24 Practice Some very good examples of services for family members but provision is patchy Implementation of evidence based practice remains low Potential to improve availability and response to families

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

26 Implementation Implementation is not the responsibility of service deliverers alone. There is a clear role here for national and regional policy makers / commissioners of services, in recognising that the evidence suggests a move away from individualistic approaches towards ones more rooted within people s s social context and social networks. They, too, have a responsibility to support and encourage services to shift from their individualistic stance towards a more socially inclusive provision [Copello, Templeton and Velleman,, 2006].

27 Policies and Guidelines Policies and Guidelines Drug Strategy 2008 NICE Guidelines 2008 & NTA Guide 2008

28 Clinical practice recommendation Clinical practice recommendation Behavioural couples therapy should be considered for people who are in close contact with a non-drug drug- misusing partner and who present for treatment of stimulant or opioid misuse (including those who continue to use illicit drugs while receiving opioid maintenance treatment or after completing opioid detoxification. The intervention should: Focus on the service user s s drug misuse Consist of at least 12 weekly sessions Taken from Drug Misuse: Psychosocial Interventions: The NICE Guideline, published by The British Psychological Society and The Royal College of Psychiatrists (2008) p.179

29 Clinical practice recommendations Clinical practice recommendations Where the needs of families and carers of people who misuse drugs s have been identified, staff should: Offer guided self-help, typically consisting of a single session with the provision of written material Provide information about, and facilitate contact with, support groups, such as self-help groups specifically focused on addressing families and carers needs Taken from Drug Misuse: Psychosocial Interventions: The NICE Guideline, published by The British Psychological Society and The Royal College of Psychiatrists (2008) p.205

30 Clinical practice recommendations Clinical practice recommendations Where the families of people who misuse drugs have not benefited,, or are not likely to benefit, from guided self-help and/or support groups and continue to have significant problems, staff should consider offering individual family meetings. These should: Provide information and education about drug misuse Help to identify sources of stress related to drug misuse Explore and promote effective coping behaviours Normally consist of at least five weekly sessions Taken from Drug Misuse: Psychosocial Interventions: The NICE Guideline, published by The British Psychological Society and The Royal College of Psychiatrists (2008) p.205

31 So, where are we now? So, where are we now? Some evidence informing developments Need a flexible approach that can be used to respond to the range of needs Service providers need models, training and support

32 Despite the available evidence and 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

33 Thank you for listening

34 Some selected useful references Some selected useful references Copello, A., Templeton, L., Velleman,, R., Orford,, J., Patel, A., Moore, L. and Godfrey, C. (2009). The relative efficacy of two primary care brief interventions for family members tions for family members affected by the addictive problem of a close relative: a randomi affected by the addictive problem of a close relative: a randomised trial, sed trial, Addiction,, 104, Copello, A., Templeton, L. and Velleman,, R. (2006) Family Intervention for drug and alcohol misuse: Is there a best practice? Current Opinion in Psychiatry, 19, (Invited review) Copello, A., Velleman,, R. and Templeton, L. (2005) Family interventions in the treatment ent of alcohol and drug problems. Drug and Alcohol Review.. 24, 4, Copello, A. and Orford,, J. (2002) Addiction and the Family: Is it time for services to take notice of the evidence? Addiction,, 97, Copello, A., Orford,, J., Velleman,, R., Templeton, L. & Krishnan, M. (2000). Methods for reducing alcohol and drug related family norm in non-specialist settings. Mental Health,, 9, specialist settings. Journal of Orford,, J., Natera,, G., Copello, A., Atkinson, C., Tiburcio Mora, J., Templeton, L.., & Walley Walley,, G. (2005) Coping with Tiburcio,, M., Velleman,, R., Crundall,, I., Coping with Alcohol and Drug problems: the Experiences Of Family Members In three Contrasting Cultures.. London; Taylor and Francis. Velleman, R., Arcidiacono, C., Procentese, F. and Copello, A. (2008). A 5-step 5 intervention to help family members in Italy who live with substance misusers, Journal of Mental Health Health,, 17,