Family interventions in the treatment of alcohol and drug problems

Transcription

1 Drug and Alcohol Review, (July 2005), 24, Family interventions in the treatment of alcohol and drug problems ALEX G. COPELLO 1, RICHARD D. B. VELLEMAN 2 & LORNA J. TEMPLETON 2 1 Birmingham and Solihull Substance Misuse Services and School of Psychology, University of Birmingham, UK and 2 Mental Health Research and Development Unit, University of Bath, UK and Avon Witshire Mental Health Partnership NHS Trust Abstract Alcohol and drug problems affect not only those using these substances but also family members of the substance user. In this review evidence of the negative impacts substance misuse may have upon families are examined, following which family-focused interventions are reviewed. Several family-focused interventions have been developed. They can be broadly grouped into three types: (1) working with family members to promote the entry and engagement of substance misusers into treatment; (2) joint involvement of family members and substance misusing relatives in the treatment of the latter; and (3) interventions responding to the needs of the family members in their own right. The evidence base for each of the three types is reviewed. Despite methodological weaknesses in this area, a number of conclusions can be advanced that support wider use of family focused interventions in routine practice. Future research needs to focus on (1) pragmatic trials that are more representative of routine clinical settings; (2) cost-effectiveness analyses, in terms of treatment costs and the impact of interventions on costs to society; (3) explore treatment process; and (4) make use of qualitative methods. In addition, there is a need to define more clearly the conceptual underpinnings of the family intervention under study. [Copello, AG, Velleman RDB, Templeton LJ. Family interventions in the treatment of alcohol and drug problems. Drug Alcohol Rev 2005;24: ] Key words: alcohol, drugs, family, intervention, substance misuse. Introduction Alcohol and drug problems are highly prevalent in society [1 4]. As these problems occur in the context of the family, it can play a major role in both prevention and treatment. It is also recognized that alcohol and drug consumption is linked strongly to other problems such as domestic violence, homelessness and crime [5 8]. As a result of these problems, a significant number of close family members of people with alcohol and drug problems are themselves at risk of experiencing stressful circumstances. Orford [9] suggested that it is important to consider families affected by addiction problems for two important and related reasons: first, family members in these circumstances show symptoms of stress that merit help in their own right; and secondly, involvement of family members in the treatment of their relatives with addiction problems can enhance positive outcomes. This review will briefly explore the impacts of substance-related problems upon families before reviewing the evidence base for family treatments used in the addiction field. The main focus will be on interventions used with alcohol and drug problems where there is some evidence of effectiveness from research evaluation. A companion review [10] examines the research on the role of the family in relation to young people using and misusing alcohol and drugs, and at interventions aimed at using the family to prevent substance use and misuse among young people. The impact that substance misuse can have on the family There is a solid evidence base for the negative effects of substance misuse in the family: especially with spouses and parents [11 28] and with children [29 36]. Alex G. Copello PhD, MSc, BSc, Clinical Director, Birmingham and Solihull Substance Misuse Services and Senior Lecturer, School of Psychology, University of Birmingham, Richard D. B. Velleman PhD, MSc, BSc, Professor of Mental Health Research, University of Bath and Director of the Mental Health Research and Development Unit, University of Bath and Lorna J. Templeton MSc, BSc, Senior Researcher and Manager of the Alcohol, Drugs and the Family Research Programme, Mental Health Research and Development Unit, University of Bath, UK. Correspondence to Alex Copello, School of Psychology, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. a.g.copello@bham.ac.uk Received 10 November 2004; accepted for publication 20 January ISSN print/issn online/05/ ª Australasian Professional Society on Alcohol and Other Drugs DOI: /

2 370 Alex G. Copello et al. Early research into the impact of substance misuse on spouses was conducted by Orford [17,37], and subsequent research has extended the work to look at the impact on a wide range of family members, examining the differential impact of alcohol versus drugs, and the differential impact of being a parent, a partner or another family member [18,27]. Research has also examined this area from a cross-cultural perspective, comparing the impact on family life in relatively economically advantaged urban and rural areas of the South West of England, with the impact on a largely economically deprived population (urban slum dwellers) in Mexico City (with issues of poverty, overcrowded accommodation, and environmental pollution) [19,20,21,38] and with both urban and rural indigenous Aboriginal inhabitants in Australia (where similar issues of economic deprivation exist, coupled with major cultural dislocation and institutionalized racism) [22,39,40]. In addition, there is a solid evidence base for the impact of substance misuse on children, both as children and when adults. A very large number of studies demonstrate negative effects on children while they are still young and in early adolescence (reviewed by Velleman [26,35]). These studies show that many of these children experience negative childhoods, including high levels of violence [41] and inconsistency from one or both parents [42 44]. Children may also have to adopt responsible or parenting roles at an early age [34]. They also show that many of these children subsequently demonstrate negative effects of these experiences. These problems include higher levels of behavioural disturbance, antisocial behaviour (conduct disorder) [45 47], emotional difficulties [34,48], school problems [49], precocious maturity [36,50] and a more difficult transition from childhood through adolescence [36,50] than children who have not had this upbringing. In another review, Kroll [51] used content analysis to review seven largely qualitative studies that investigated the impact of parental substance misuse on children (five UK studies four alcohol, one drugs and two US studies). Kroll s analysis showed that the children s lives were affected by six overarching themes: denial, distortion and secrecy; attachment, separation and loss; family functioning, conflict and breakdown; violence, abuse and living with fear; role reversal, role confusion and child as carer; and what the children said they needed. Many of these themes had already been picked out in previous research [31]. Other recent work has also shown that increased concerns about these children s welfare and about their needs under child protection legislation means that children affected by their parent s substance misuse are more likely to reach the attention of social services than are children affected by other issues [52,53]. However, further challenges arise when these children (and their families) are seen by professionals in substance misuse and/or child-care services. A recent qualitative study [54] with 40 professionals from a range of settings identified five broad themes, corresponding to and developing further the work above. These themes are seen as dilemmas and barriers to effective work, particularly within social care, with children affected by parental substance misuse. The themes identified were: (1) engagement (with access to the children often being denied); (2) conflicting agency focus (adult needs or child needs); (3) inter-agency communication (especially related to the issue of confidentiality); (4) conflicting assessment needs (assessment of substance misuse vs. assessment of parenting); and (5) children having significant needs but remaining largely invisible. These findings have implications for the development of practice and policy in this area. There is also an increasing amount of research that demonstrates longer-term impacts on these children. The children of those with alcohol (and drug) problems are more likely to develop problems with substances themselves are often linked to earlier onset of use [36], and therefore can be at greater risk of developing problems in other areas of life [55 58]. Again, family factors seem to predominate, and adults who were the children of problem drinkers reported more problems, both when they were children and upon reaching adulthood, as a result of family dysfunction and disharmony than from the drinking itself [36]. On the other hand, there is also growing evidence that not all children are adversely affected, either as children or adults [32,34,36,45,59]; some children are resilient and do not develop significant problems. This has important implications for prevention and intervention [60]. As a result of these and other studies, it can be concluded that individuals who develop a serious problem with their use of alcohol or drugs can and often do behave in ways that have a significantly negative impact on family life in general, and on other members of the family. The substance misuse can impact negatively on a range of family systems and processes, including family rituals, roles within the family, family routines, communication structures and systems, family social life and family finances. The substance misuse can also impact negatively on other individuals within the family. Problems such as domestic and other types of violence, child abuse, individuals driving while intoxicated or disappearing for days on end are all typical types of behaviour that people have described as stressful and with which they have to cope. The results of these and other uncertainties are that family members commonly develop problems in their own right, often manifested in high levels of physical and psychological symptoms (e.g. [61]).

3 Family interventions and substance misuse 371 In conclusion, family members suffer biopsychosocial stresses as a result of living in this environment, which may impact on physical and mental well-being and lead to the development of problems both for themselves and other family members [27,62]. This is a world-wide phenomenon [16]. These family members need help, both for themselves, and in relation to dealing with their substance misusing relation. Between a third and half of calls to alcohol advice centres in the United Kingdom come from partners, families and friends [63]. The remainder of this review focuses on intervention strategies that have aimed to work with families affected by substance misuse problems. Family interventions in substance misuse Two recent reviews of family interventions [22,64] summarize the range of interventions for family members. These tend to fall into three broad areas: (1) working with family members to promote the entry and engagement of misusers into treatment; (2) the joint involvement of family members and misusing relatives in the treatment of the misuser; and (3) responding to the needs of the family members in their own right. Working with family members to promote the engagement of substance misusers into treatment The idea that family members can influence those with alcohol and drug problems by helping the user to decide to seek or accept help for the problem has received considerable attention in the recent research literature. There is evidence to support the view that family involvement can help engage the substance user in treatment [65,66], and there have been a number of research studies evaluating interventions designed with this specific purpose. Barber & Crisp [5] developed the pressures to change approach designed to work with the family member (spouse) of someone with a drink problem in the absence of the latter. The approach starts by engaging the family member in treatment focused on education; discussion of family member s response to drinking situations; setting up activities incompatible to drinking; and preparing the family member to confront the person with the drink problem and request that he/ she approaches services to seek help. In essence, the approach aims to change the behaviour of the family members concerned, so that the person with the drink problem enters into treatment. In a controlled study, Barber & Crisp [5] randomized family members to one of three groups: pressures to change in individual (n ¼ 8) or group (n ¼ 8) format or waiting-list control (n ¼ 7). The study targeted those people with drink problems in the precontemplation stage of change as defined by Prochaska & Di Clemente [67]. The authors reported that more people with drink problems entered treatment after their family members were involved in the pressures to change approach, with no differences between the individual or group format. Overall, no significant improvements were found for family members well-being, self-esteem, depression or marital discord. Barber & Gilbertson [68] conducted a further evaluation with a slightly larger sample (n ¼ 48) and compared four interventions: (1) pressures to change delivered on an individual basis; (2) pressures to change in group format; (3) no treatment control; and (4) Al-Anon group. Positive changes were reported for 16 of the 24 participants who received the pressures to change approach and who, following the intervention, met the established criteria for change defined as either seeking treatment, ceasing drinking for a minimum of 2 weeks or reducing consumption to a previously agreed level. No changes were reported in the other two groups. CRAFT (Community Reinforcement and Family Training) [69 71], an extension of the Community Reinforcement Approach (CRA) [72 74], is another example of a method that aims to work with concerned significant others (CSOs) to reinforce non-substancemisusing behaviour through a positive reinforcement process. The essence of CRA is the restructuring of social, family and vocational aspects of everyday living of those with substance use problems, so that abstinence from drugs or alcohol is selectively encouraged. The CRA approach had always tried to use concerned significant others (CSOs) in a variety of ways: as Disulfiram (antabuse) monitors, partners in marital counselling, active agents in re-socialisation and reinforcement programs, and detection monitors for relapse [70]. However, the development of the CRAFT programme (Community Reinforcement and Family Training) has allowed this area to be further developed. This occurred because their observations of the effectiveness of spousal involvement in therapy and the fact that many substance abusers were resistant to treatment led to the creation of a reinforcement training programme for spouses and family members of treatment resistant substance abusers (pp ). The CRAFT approach was developed from a long tradition of approaches focused on the influence of the family, and other social and vocational aspects of those with drinking problems, in terms of reinforcing abstinence and assisting substance related behaviour change [72 75]. Sisson & Azrin [76] used this behavioural approach to give community reinforcement counselling to 12 relatives; they reported positive results on the alcohol misuser seeking treatment and reducing their drinking. Guided by the above principle, CRAFT has adapted a number of intervention strategies to work directly with CSOs of treatment-resistant

4 372 Alex G. Copello et al. substance users, and has been examined with both alcohol and drug-misusing populations. CRA and many of its key components have been identified in several meta-analytical reviews of treatment for serious alcohol problems as having among the highest levels of treatment efficacy [77 80]. Meyers et al. s [71] study of CRAFT recruited 62 concerned significant others, 74% of whom managed to engage successfully their previously treatment-resistant drug-misusing relative into treatment. This also led to a reduction in physical and psychological symptoms for the non-misusing family member. Miller et al. [81], working to engage people with alcohol problems into treatment, randomized CSOs to one of three interventions: CRAFT (n ¼ 45); benevolent confrontation / Johnson Institute approach (e.g. [82] (n ¼ 40); and Al- Anon facilitation (n ¼ 42). Results showed that CRAFT was significantly more effective in engaging resistant problem drinkers into treatment within the 6 months following the intervention (64%) compared with Al- Anon facilitation (13%) and Johnson Institute (30%), although all three conditions led to improvements in psychological functioning for the CSOs. Miller et al. [81] argue that an improvement to this area of research would involve the use of qualitative data to explore and understand further a number of important issues, such as how family members had applied the skills developed during the intervention and whether changes in coping behaviour occurred over time. A further study [71] used the CRAFT approach with CSOs of treatment resistant drug users. Their sample included parents as well as partners. The authors reported that 74% of the drug users attended an assessment as a result of the intervention with their concerned family members. Of this group, 95% were reported to attend the first treatment session of a 12-session programme. Those who entered treatment showed more abstinent days over the 6-month period of the study than did those who did not enter treatment. There have been a number of other interventions aimed at assisting treatment entry through the influence of concerned family members. Yates [83] found that problems with someone else s drinking were more likely to be reported than were problems related to personal drinking. On this basis, a co-operative counselling service was established and evaluated, which worked with affected others to encourage problem drinkers into treatment. The emphasis of Yates s approach is the development of a coordinated strategy for change working with those concerned enough to take positive action in response to the drink problem. Results indicated that relatives valued the help that was offered to them, in particular receiving confirmation that the drinking was a serious issue and advice on developing effective strategies to use with the drinker. Working with affected others brought several problem drinkers into treatment: Yates reported that in 50% of a sample who took part in his study (n ¼ 30), resistant drinkers agreed to approach treatment services. Although seen as relatively successful, Yates s study has not been replicated in the United Kingdom. In the United States, however, such approaches are more widely available [84,85]. Other interventions have been developed from the basis that family members can be important in breaking down denial and increasing pressure on people with drink problems to enter treatment. The Johnson Intervention is one such example [86]. As part of this intervention, the social networks of people with alcohol problems are trained to stage a confrontation, during which attempts are made to reduce denial about alcoholism and engage the person in treatment. The limited evaluations of this intervention have shown that a small number of trained social networks go on to carry out the confrontation but in most cases, despite preparatory work, the confrontation never occurs [82]. There is also some evidence in the literature that when people enter treatment as a result of these techniques, retention in treatment is low and relapse rates are high [87,88]. An approach that has been developed from the Johnson s Institute Intervention is called A Relational Intervention Sequence for Engagement (ARISE) [89]. This approach, although developed originally from Johnson s Intervention, places less emphasis on the confrontation and more emphasis on support for the user and family member prior to, during and after treatment entry. Garrett et al. [90] describe a series of strategies based on the ARISE approach that can be used in response to a concerned relative of a substance user contacting an addiction agency for help. The aim of the response is to mobilize family members and social networks to influence treatment engagement for the substance user. The authors report the results of an ongoing study using this approach where over 100 calls from concerned others were taken using the methodology described, and in 65% of cases the substance user entered treatment or self-help. Substances included alcohol, cannabis, cocaine, heroin and various combinations of these drugs, and family members included parents, partners and siblings. The approach is not confined to family members and some calls were also received from co-workers and employers. Galanter s network therapy [91,92] also involves the engagement of social networks to help the substance misuser and the wider family. Here, the misuser, a key significant other (usually, but not necessarily, a relative) and other relatives, friends and significant others (for example, a work colleague or other professional) are all engaged in work on someone s substance misuse. The family is seen as central to co-attend therapy sessions with the

5 Family interventions and substance misuse 373 misuser, to introduce and maintain the misuser into treatment, and then to prevent relapse. Most of the studies reviewed above deal with the engagement of adults into treatment. Liddle s recent review [66] suggests that such techniques also work with adolescents, concluding that family-based engagement strategies can make a significant difference in the treatment engagement rates of youths and families [66, p. 79]. The literature reviewed within this section shows consistently that working directly with those concerned about someone else s substance use can lead to engagement of the user in treatment. There are, however, a number of weaknesses to be noted. Most studies are based on small sample sizes and some of the studies lack control groups; therefore generalizability is uncertain. In addition, the over-reliance on quantitative measurement means that little is known about the processes of change. On the positive side, however, results from both controlled and uncontrolled studies are very consistent at least in supporting the influential role of family members in relation to treatment entry of the substance user. These results have been replicated across various groups of family members using a range of substances, and more rigorous controlled evaluations have been conducted in the alcohol area. These findings challenge the powerful myth widely held within the substance misuse problems and therapy field: that family members concerned about a relative s substance misuse cannot influence them to change. It is true that family members cannot make an individual stop drinking or using drugs, but they can change their own behaviour in ways that will help the misuser recognize that the substance use is problematic and that change is desirable. The studies reviewed above support the effectiveness of such interventions. Further, if interventions are offered to family members in their own right (e.g. to help them cope better, or help them to develop improved social networks), there are significant effects in terms of reduced symptoms and altered coping mechanisms [93] which in turn impact on the drinker s behaviour. The following section examines studies that attempt to treat people with substance related problems using family interventions. Joint involvement of family members and substance-misusing relatives in treatment The approaches reviewed above certainly help to bring people with substance misuse problems into treatment. Some of the interventions reviewed as well as other approaches can also help to change substance use behaviour, and to reduce levels of both consumption and of problems. It has been known for some time that the quality of family relationships impacts on someone s substance misuse [94] and that positive marital and family adjustment is related to positive treatment outcomes [17,37,95,96]. There is also a growing evidence base for behavioural, community-reinforcement and family approaches. A number of examples of studies show that involvement of concerned others can lead to improved outcomes in both alcohol treatment (e.g. [97 99]) and drug treatment (e.g. [100,101]). A number of scholarly reviews, meta-analyses and systematic reviews [77,84,85,102,103] have shown that the social component of treatments for alcohol problems (e.g. community reinforcement, behavioural marital therapy) is highly effective. Hence Edwards & Steinglass s [84] review of 21 studies of interventions which involved family participation concluded that these interventions were both helpful and cost-effective; two major reviews of behavioural couples treatment of alcohol and drug problems [102] and family/couples treatment for drug problems [103] confirm the improvement in outcomes associated with family involvement; and the recent review of family based therapies for adolescent alcohol and drug problems [66] demonstrated that such family-based interventions had a major positive impact on engagement, retention and treatment outcomes. Miller & Wilbourne [77] showed that three of the top eight most effective treatments for alcohol problems were ones that were highly social in nature: behavioural marital therapy; community reinforcement; and social skills training. As they concluded: Attention to the person s social context and support system is prominent among several of the most supported approaches (p. 276). Two of these treatment approaches (behavioural marital therapy and community reinforcement) have a major focus on couple and family functioning. One of the most interesting (and one which demonstrates best how much families and couples do work as a system) is unilateral family therapy (UFT: [104,105]). UFT uses a systemic model that suggests it is possible to alter the ways that a family works without all members of the family system being present in therapy sessions. Thomas and colleagues suggested that it is possible to alter someone s substance misuse, even if they never present for treatment. Working with other members of the system and helping them to change their behaviour will, it is argued, impact on the user s behaviour. This approach works with the concerned family member alone, aiming to affect change through working with the spouse in the absence of the person with the drinking problem. This approach was designed to be most suitable for attracting the most unmotivated, treatment-resistant [drinkers] [75]. Most of their work has been undertaken with family members of people with alcohol problems, where they have trained the partner of the

6 374 Alex G. Copello et al. person with the drink problem in order to act as a rehabilitative influence. For example, Thomas et al. [106] used UFT in a small study of 25 family members, 15 of whom received the UFT intervention and 10 a non-treatment condition. They reported a 53% reduction in alcohol consumption in those users whose family members received the intervention and a slight increase in consumption in the control group; and that for eight of the problem alcohol users whose family member received treatment, the drinking was reduced or the drinker entered treatment compared to none in the control group. In a later study of UFT, Thomas & Ager [104] reported that 57% of drinkers entered treatment compared to 31% in the no-treatment control condition. Interventions were delivered over a period of 6 months and aimed to improve family member coping and family interactions and encourage treatment entry for the drinker. UFT has been shown to produce far greater rates of subsequent entry into treatment on the part of the drinker and decreases in their drinking, even though they did not attend the family therapy sessions. This evidence suggests that there is a set of therapeutic strategies which can help the family respond constructively to a family member s alcohol problem and motivate the drinker to change or seek treatment, even if the drinker does not attend for help. Other approaches focus on interactions between family members and substance misusers more directly. Of course, most family interventions do not work by acting with the family member alone, and many do not aim solely to reduce substance use; they focus on improving relationships, decreasing behaviours that facilitate substance misuse, and increasing marital or family stability and happiness. In essence, these strategies aim to alter the conditions within the client s environment in order to support change [107, p. 345]. A key intervention relates to marital (or couples) therapy. For many years marital (or couples) therapy has been evaluated as a treatment for alcohol problems (e.g. [108,109]). Involving the spouse in treatment for alcohol problems has been found to produce better outcomes than has individual treatment that excludes the spouse (e.g. [108,110]). Therapy which involves the alcohol misuser s partner can remain focused on the alcohol problem (and on the partner s role in supporting or assisting the client in their change), or it can include direct attempts to improve marital functioning, which is predicted to have a knock-on effect on the drinker s drinking. However, although a variety of marital therapy approaches have been used, including joint hospitalization of marital couples, group therapy for married couples, intensive short-term family intervention programmes (i.e. 3 7 days as part of Minnesota model in-patient treatment, day treatment for married couples, Al-Anon, family education, confrontational family sessions, marital systems treatment, etc.), most of these approaches have not been subjected to research evaluations; and comparisons between different approaches are lacking [111]. Only marital therapy conducted from a behavioural orientation has undergone extensive evaluation, which has shown it to be an effective technique for alleviating marital distress and impacting on alcohol related problems (e.g. [97, ]). Alcohol-focused behavioural couples therapy (ABCT) is a structured therapy based on cognitive behavioural principles of behaviour change [115]. Major components of ABCT include [94]:. Cognitive behavioural strategies that will help the drinker stop drinking and acquire coping skills to respond to both drinking-specific and general life problems;. Strategies that teach family members to support the drinker s efforts to change, reduce protection for drinking-related consequences, develop better skills to cope with negative affect, and communicate around alcohol-related topics;. Strategies to improve the couple s relationship by increasing positive exchanges and improving communication and problem-solving skills;. Behavioural contracts between intimate partners to support the use of medication [116]. Marital therapy for alcohol problems typically has two major objectives: to alleviate distress and encourage positive adjustment in the marital relationship; and to reduce alcohol problems. Usually it is thought that better marital relations will serve to reduce alcohol problems. Thus, studies typically measure two outcomes: effects on the marriage and effects on drinking. Research [117,118] suggests that ABCT results in greater marital happiness after treatment, fewer incidents of marital separation and fewer incidents of domestic violence. Many also report that ABCT leads to greater improvements in drinking behaviour than comparison treatments, although study results here are mixed. Some studies have found short-term effects (i.e. for a few months) on drinking that are no longer so strong at longer intervals (e.g. [98,113]). Others have been more positive: based on follow-up assessments at 6 months, couples undergoing behavioural marital therapy relapsed more slowly after treatment than comparison conditions, and were also more likely to complete treatment [97]; at 18 months after treatment, the rate of abstinence among the couples who had received behavioural marital therapy had gradually continued to improve after treatment ended rather than dropping off, as occurred with the comparison conditions [108]. These couples also reported enjoying

7 Family interventions and substance misuse 375 greater relationship satisfaction with fewer marital separations. In support of the finding of continued improvements for couples whose behavioural marital therapy treatment had ended, Stout and colleagues reported the same pattern of improvement 2 years after a similar BMT trial with a different sample of 229 clients with alcohol use disorders [99]. Similar BMT approaches have been applied successfully in relapse prevention [119], with booster sessions spread out over the following year [120]. According to Noel & McCrady, this long-term effectiveness suggests that marital therapy may prevent relapse during early recovery by stabilizing the substance user s interpersonal context [121]. Family systems therapy is another important area that views drinking as one aspect of the marital/family relationship and focuses on altering couple interactions that might be sustaining the drinking, as well as each partner s views of the meaning of the drinking. It may not be necessary to require abstinence from drinking, but rather to help couples select and pursue a drinking goal of their own choosing. Both strategic and structural family therapy techniques can be used to manage clients ambivalence about change. One empirical study has tested the effectiveness of family systems therapy to treat alcohol problems in adults. Preliminary results suggest that such approaches are more effective than cognitive behavioural approaches in retaining resistant and angry clients in therapy [122]. There has been a great deal of interest in a variety of types of family therapy for drug misuse, including structural strategic therapy, Bowen type therapy and contextual family therapy [65,101, ]. Controlled trials have shown that family therapy is more effective than control conditions in engaging drug misusers, and superior at post-treatment or follow-up in terms of drug use or family functioning. Familybased treatments aimed at adolescent substance misusers have been shown to lead to improved rates of school attendance and performance, improved family functioning, and reduced behavioural problems associated with the substance misuse [66]. Family approaches utilize close (and sometimes wider) family. Network therapy [91,92], outlined briefly above, follows the relatively new (and mostly developed in the United States) idea that better success in treatment of misusers can take place if positive social networks are involved. Incorporating elements of cognitive behavioural therapy, network support and community reinforcement, Galanter has reported the results of an evaluation of network therapy work with cocaine misusers and their family and peers [92,127,128]. The work with 60 patients showed improvements for the substance user and illustrates some of the interesting processes that occur within the therapy: three-quarters of those in the study (n ¼ 47) engaged at least one network member; and number of network sessions were associated with more significant outcomes compared with individual sessions. Finally, social behaviour and network therapy (SBNT), developed recently in the United Kingdom [107,129], is a synthesis of many of the family and social network ideas reviewed above. SBNT was one of the two treatment approaches (the other was motivational enhancement treatment) delivered in the recently completed UK Alcohol Treatment Trial (UKATT). SBNT is based on the premise that to give the best chance of a good outcome people with serious drinking problems need to develop positive social network support for change [107]. The treatment has been written in manual form and was delivered over eight sessions. As part of the treatment the therapists attempt to engage the misusers network members in the sessions and uses strategies aimed at developing positive support for a change in the substance-misusing behaviour. The UKATT trial [130] involved a large randomized comparison of SBNT and MET in a range of treatment services in the United Kingdom. The UKATT trial has been completed recently and results will be reported in due course. Results involved both analyses of main outcomes between the two approaches, exploration of matching hypotheses (i.e. did either treatment achieved better outcomes with particular client groups) and a full cost-effectiveness and economic analysis. UKATT results will add to the developing body of research in this area. In addition, a feasibility study of the implementation of SBNT in drug misuse treatment has been reported [129,131], showing promising outcomes in terms of drug misuse reductions and high levels of acceptance among both therapists in routine drug services and clients with drug problems. In terms of evaluation of the types of interventions reviewed in this section, the picture is a mixed one. On one hand, all the treatments outlined above have resulted in either equal or usually better outcomes than approaches that do not involve the substance misuser s family; most show, in the long term, an increase in the number of days spent abstinent compared to interventions which do not use or minimally involve spouses and other family members. On the other hand, the majority of studies have suffered from having low numbers of participants, weak or absent control groups, and disappointing follow-up rates. It is therefore difficult to draw robust and confident conclusions. Certain approaches stand out. The behavioural marital or couples therapy approach of O Farrell & Fals-Stewart and their colleagues in the United States has been the subject of a whole programme of welldesigned studies. The emphasis has been upon engagement of the problem substance using relative in treatment and subsequent reductions in alcohol or drug

8 376 Alex G. Copello et al. use, but there have also been reports from that programme of improvements in marital adjustment and reductions in levels of domestic violence (e.g. [109,132]). Social behaviour and network therapy (SBNT), has been studied recently in a large multicentre trial in the United Kingdom and results will be available shortly. However, it is of note that family member outcomes were not evaluated systematically. A review of a number of controlled trials of family therapy in the treatment of problem drug use concluded that treatments involving partners or other family members (i.e. couples or family therapy) were more effective than methods that did not, although outcomes were confined to assessments of drug use [103]. The CRAFT approach has been the subject of two well-designed trials which found the method to be more effective than others in engaging problem using relatives in treatment [81,133]. In the Miller et al. [81] study, improvements for family members in terms of anger, depression, family conflict and family cohesion were reported irrespective of whether the problem drinking relative entered treatment. We would agree with Miller et al. s [81] suggestion that an improvement to this area of research will involve not only the better use of good trial methodology, but also the collection of qualitative data in order to explore and understand in more detail important issues such as: (1) what aspects the family members find to be of benefit in an approach such as CRAFT and (2) how changes occur in family ways of coping, family cohesion and family members health and well-being. Interventions aimed at supporting those family members affected by the substance misuse of a relative A further area of family intervention includes approaches that are aimed at family members affected by alcohol and drug problems and which see the family members as the main target for the intervention. One of the interesting paradoxes in this field is that, despite the fact that a number of family interventions have been developed and evaluated, and despite the recognized influence of family members as agents of change in relation to the substance user s behaviour, little or no attention has been paid to processes or impacts on family members as opposed to the problem drinker or drug user. As examples, until recently most studies of family interventions aimed at treating substance misusers did not measure changes in symptoms in family members or change in the family members coping behaviours following a family intervention. In addition, the needs of the families of substance misusers have been largely ignored in service provision [134]. It is likely that this is a reflection of the fact that the primary focus has been on the outcomes for the substance user, with family members being conceptualized (if at all) as adjuncts in the treatment process or agents who can influence the substance user s behaviour. This neglect has been attributed to a consequence of the lack of a family orientation in professional training and practice, plus the existence of a number of models of family functioning that cast family members in a negative light [22, ch. 10]. There is evidence in the United Kingdom that this is slowly changing: a recent survey conducted by Alcohol Concern [135], the National UK alcohol agency, found 59 agencies which offered some level of help to families and/or children affected by alcohol misuse. This is a marked increase over the numbers in a previous survey by Robinson & Hassell [136], who found only 14 such agencies in their survey. However, even in this more recent work, 78% of respondents felt that the work with children and families was not meeting their apparent needs. Although there is a lack of direct work with families affected by substance misuse, evidence is emerging for the effectiveness of interventions aimed at these family members in their own right. The UK Alcohol, Drugs and the Family Research Group [137] have undertaken a number of studies of interventions aimed at reducing family members stress and strain. On the basis of the results from previous studies on the impact on family members living with a substance misusing relative (e.g. [19 21], and the subsequent development of the stress strain coping support model (SSCS; [22,137,138]), Copello et al. [93,139] developed a five-step approach involving (1) giving the family member the opportunity to talk about the problem; (2) providing relevant information; (3) exploring how the family member responds to their relative s substance misuse; (4) exploring and enhancing social support; and (5) discussing the possibilities of onward referral for further specialist help. They demonstrated that this approach was effective in reducing family members signs of strain (a significant reduction in both physical and psychological symptoms) and positively altering and enhancing their coping mechanisms [93,139]; they also showed an improvement in the attitudes held and motivation towards working with relatives of substance misusers in the primary health-care professionals involved in delivering the intervention [93,139]. This same fiovestep approach has also been tested with a small sample in the specialist secondary care setting [140]. Results from all these studies are positive, demonstrating that the intervention can lead to changes in coping, improvements in social support and reduction in physical and psychological symptoms. Qualitative data have shown that family members greatly appreciate the opportunity to talk about and reflect upon their situation, and consider how positive change can be achieved. There is also some evidence that the

9 Family interventions and substance misuse 377 intervention can, in some cases, lead to a change in the problem alcohol or drug consumption of the relative and that this in turn can lead to improved family relationships. Earlier work by some members of the same group [141,142], again using an earlier version of the SSCS model described above, developed counselling in their own right for partners of problem drinkers. The counselling, mostly delivered by trained volunteers as part of specialized secondary care services, emphasized the stress experienced by partners and ways of coping with it. A before after comparison showed significant reductions in self-sacrificing and engaged coping and in level of common symptoms. Detailed case studies, a comparison with a small delayedtreatment control group and partial follow-up to 12 months provided supportive evidence of positive outcome and detail of process. Most of the other work that has been undertaken to engage and help family members affected by the excessive drinking or drug-taking of close relatives has been conducted in the United States, with some contributions from the United Kingdom, Australia, Canada and former Yugoslavia. The CRAFT approach, described above in the section on using family members to facilitate engagement of substance misusers into treatment, although designed as a method of improving the engagement of people with substance misuse problems into treatment, also looked at its impact directly on family members. As outlined above, CRAFT [69,70,71] is an extension of the community reinforcement approach (CRA) [72,73,74] and aims to work with CSOs to reinforce non-substance-misusing behaviour through a positive reinforcement process. The essence of CRA is the restructuring of social, family and vocational aspects of everyday living of those with substance use problems, so that abstinence from drugs or alcohol is selectively encouraged. The development of the CRAFT programme has allowed the use of CSOs to be developed further. An evaluation of the approach with 62 family members of drug misusers reported that all CSOs showed significant reductions in family conflict, depression, anxiety, anger and physical symptoms, with average scores dropping into the normal range on all measures, as well as improvements in family cohesion [71]. Of interest was the result that these direct and personal benefits to the family members occurred regardless of whether or not their relative did or did not enter treatment. Dittrich and colleagues [143,144] developed and evaluated a psychoeducational approach. Based on their understanding of alcoholism as a family disease, their intervention attempted to increase understanding of alcoholism and family interaction; identify and decrease enabling behaviours (described as emotional, behavioural, or cognitive reactions to the alcoholism that are counterproductive to the wife s self-esteem and also inadvertently reinforce the husband s continued drinking [143, p. 86]; instead ideas from Al-Anon of detachment and responding versus reacting were promoted) increase self-esteem; and decrease depression and anxiety. Their approach was organized in three phases: educational, experiential (in which assertive responses are practised) and goal-setting and planning. In a small randomized trial, 10 women married to men with alcohol problems who received the intervention compared to 13 women on a waiting-list control showed greater change in self-concept, depression and anxiety, and in enabling behaviours. The delayed-treatment group subsequently showed the same changes. At 12 months follow-up half the women were still meeting informally or attending Al-Anon, over a third were divorced or separated and half the husbands had entered treatment or mutual-help (even though this was not the main objective of the intervention). More recently, Halford et al. [145] have compared three interventions in a randomized controlled trial of three forms of help for women partners of men with alcohol problems: supported counselling versus stress management versus alcohol-focused couples therapy. The sessions were based, respectively, on education and non-directive counselling [146]; reducing the stressful impact of the problem for the family member and help to influence the partner s drinking [76]; and behavioural couple therapy based on contingency reinforcement of efforts to control drinking and communication and problem-solving training for the couple [147]. Each intervention was delivered via 15 1-hour sessions, and the aims of the interventions were the same: to reduce risk of violence; assist the family member to choose whether to remain in the relationship; and to help her enact a decision to leave or alternatively to improve coping and empower her to influence the partner s drinking. Sixty-one family members were allocated at random, and the trial found reductions in psychological symptoms for family members, post-treatment and at 6-months follow-up, irrespective of type of treatment. None of the treatments produced significant reductions in relatives drinking or level of relationship stress. Only a minority of problem drinkers agreed to pursue couple treatment. In an intervention with a different orientation (enabling parents to respond more effectively to their adolescents substance use) McGillicuddy et al. [148] developed parent coping skills training. This is based on a behavioural analytical model of skill training [149], and consists of eight weekly 2-hour sessions to teach more effective coping skills in responding to their adolescents substance use. The training uses group discussion and role-play around a standard set of frequently encountered situations. The resulting small randomized

10 378 Alex G. Copello et al. trial (evaluated with parents from 22 families; 14 receiving the intervention, eight in the waiting-list control) showed greater improvement in parental coping skills, parents own functioning, family communication and the relative s marijuana use compared to waiting list control, although changes in relation to alcohol use were not different between the groups. Recently, Toumbourou et al. [150,151] from Australia reported on their Behavioural Exchange Systems Training (BEST). This is an 8-week group programme for parents of drug using adolescents, where the first 4 weeks are spent focusing on improving parents wellbeing and the later weeks aiming to increase assertive parenting responses. A quasi-experimental design with 48 families (32 offered the BEST intervention, 16 allocated to a waiting-list condition, with allocation not being random but based on time and availability of places in the programme) showed that BEST was associated with greater reductions in mental health symptoms, increased parental satisfaction and use of more assertive parenting behaviours compared to a waiting-list comparison. The latter group showed the same pattern of changes once they received the intervention. There are also many examples of smaller-scale work orientated towards helping family members. Ewing et al. [152] and Smith [153] developed concurrent group treatment : group therapy for wives of men with drinking problems, running concurrently with treatment for their problem drinking husbands. These uncontrolled studies reported positive results, but sometimes only a small proportion of partners agreed to participate. Cohen & Krause [154] wrote about their family casework approach where two types of family social work were compared, one based on a view of alcohol misuse as the primary family disorder, the other on the traditional casework view that excessive drinking was a symptom of other problems in the alcoholic and members of his family. Although they did conduct a randomized controlled trial, their high attrition and other methodological problems reduce the usefulness of this study. No improvements were reported in either group in terms of wives self-appraisal, satisfaction with family relationships, etc. They did however, report a greater level of reduced drinking in the alcohol as primary disorder group, and they also reported that this group had a high rate of divorce. Finally, the work of the self-help groups Al-Anon and Families Anonymous are important as family interventions. As anonymous fellowships evaluation used to prove difficult, but there have been a few studies of the organization [81,155,156]. These have generally provided evidence that members of Al-Anon reduce the use of controlling ways of coping. A controlled trial showed equally good outcomes for wives, in terms of depression, anger, family conflict and relationship satisfaction, as for two non-al-anon family treatment conditions. The evaluations have also shown that problem drinking husbands have relatively good drinking outcomes when their wives attend Al-Anon. Responding to the needs of children The interventions reviewed above have all concentrated on adult family members. As outlined at the start of this review, many of the family members negatively affected by a relative s substance misuse are children. There is good evidence (reviewed above) that these children frequently develop major emotional and behavioural problems as a result of living in such situations, and that they are at greater risk of developing substance misuse and other problems in turn when they reach adolescence and adulthood. There are obvious overlaps here with much of the research examined in the companion review to this present one [10] which looks at the role of the family in preventing and intervening with young people s using and misusing of alcohol and drugs. However, in a similar way as with affected adults, few services and few interventions have been developed to assist these children who are having to cope with a relative s (usually a parent s) drinking or drug-taking, either in dealing with their current distress or in trying to prevent future problems [31,52,53,54]. Cuijpers [157], in his review of the prevention programmes for children with at least one parent who has an alcohol problem, reported that work was generally lacking in this area, that what there was had been mainly undertaken in the United States, and that such programmes were inconclusive in terms of efficacy and effectiveness. He showed that prevention programmes aimed directly at these children tend to have four core components: social support, information, skills training, and coping with emotional problems (although Cuijpers emphasizes that there is no evidence that these are the most important components). School-based programmes are the most numerous, although little evaluative or outcome-based research has been conducted on them. Three discussed by Cuijpers are SMAAP, STAR and The Images Within. Positive outcomes across the three programmes include impact on social support, depression, self-esteem, loneliness, coping, seeking help and increased knowledge about alcohol. There is also a small amount of evidence (e.g. [158]) of the usefulness of a group approach, from targeting coping and social skills to intervening with the children of alcoholics, notably those whose parents are not in treatment. One example of an individual evaluation from London, UK is provided by Velleman et al. [159,160], who undertook an evaluation of a family alcohol service which aimed specifically to intervene with children affected by parental alcohol misuse.

11 Family interventions and substance misuse 379 They showed that the service had significant successes in engaging difficult-to-treat families in the change process, that the children being treated became less anxious, their coping responses improved, in some cases school attendance, achievement and relationships improved, and many were able to express and resolve long-standing negative feelings about their situations. Parents reported improvements in their functioning attributable to the service: being more able to cope, more aware of the impact that their drinking had had in the past on their children and an enhanced commitment to ensuring that any such impact would be reduced in the future. The appearance of many parents also improved over time, attributable to increases in their self-esteem. In many cases family functioning also improved with better communication, meals eaten together, joint parent child activities and many children reporting being able to regain a sense of childhood. Finally, two-thirds of the problem-drinking parents who engaged for 2+ sessions sustained abstinence, or reverted to abstinence if they had a short relapse. Parents who were not able to acknowledge the impact of their drinking on their children were less likely to engage. Other work in this area is more discursive; for example, Banwell et al. [161] discuss issues and dilemmas in running intervention programmes for children of drug using parents, and challenges that have emerged more specifically from their work with parents and children, that supports the role of playgroup-based activities. Six such challenges are discussed: achieving the right balance of intervention and trust when problems arise; the right location; right level of support for staff; multi-agency collaboration; funding (including for evaluation); and being flexible while providing a service. A qualitative study in Scotland of 62 people with drug problems who were all parents [162] highlighted the benefits and challenges of involving members of the extended family in protecting the children. Barnard argued that extended family members, particularly grandparents, have an important role to play in supporting the children but that this is not without its challenges, especially because the views and actions of the extended family often ran counter to those of the parents. Barnard suggested that being in such a situation led to a complex mix of emotions for the extended family, who had to deal with a wide variety of competing issues such as: seeing a loved one attempting to deal with a serious drug problem; dealing themselves as a parent/grandparent with the conflicting priorities of having a child with a drug problem who also had a child who needed caring for; encountering many conflicts over what the drug using person should be doing; recognizing their own duty to protect and ensure that their grandchild was cared for; and perhaps being placed in an unplanned parenting capacity themselves. Finally, a relatively new and interesting area of prevention involves supporting the children of parents convicted of drunk driving. Cuijpers [157] discussed one such programme, which found that involving both parents in the intervention programme led to better results in terms of child positive behaviour (although this was not mirrored with similar drops in negative or affective behaviour). The studies reviewed in this section provide evidence for the effectiveness of interventions aimed at family members in their own right, especially those aimed at adults. These studies suggest that family symptoms of stress, depression and other psychological problems can be reduced following relatively brief family memberfocused interventions. Similar criticisms could be levelled, however, at these studies in terms of low numbers, lack of control groups and low follow-up rates. In the final section of this review we aim to assess all three areas. What can we conclude from the literature reviewed? Three types of interventions have been reviewed: those aimed at involving the family in engaging the substance misuser in treatment; those focused on treating the misuser once they have developed problems; and those focused on affected family members in their own right. Overall, in terms of evaluation, the picture is mixed, with studies having low number of participants, weak or absent control groups and limited follow-up rates over short time-periods. Bearing these limitations in mind, we can put forward a number of conclusions. There appears to be robust evidence that working with family members affected by substance misuse can trigger treatment entry for the substance misuser. These findings are evident when working with alcohol and drug problems, although more studies have been reported with alcohol-related problems. The approaches reviewed are promising, although the evidence suggests that when procedures to engage the substance misuser become too elaborate (e.g. [86]) family members may not follow through with the intervention. Other approaches, however, suggest that even if the substance misuser does not enter treatment, outcomes for family members can still be positive (e.g. [81]) provided the treatments have elements built into them to address family member s stress and psychological well-being. There is also evidence that family involvement in treatment can be very effective. While the evidence could be strengthened, the evidence that has been published suggests that all the reviewed interventions are promising and should not be excluded from further

12 380 Alex G. Copello et al. evaluation and development. Some approaches have more robust evaluation (e.g. BCT and CRAFT). Family therapy approaches, however, have also shown good outcomes with particular emphasis on the misuser s alcohol or drug consumption. Network methods are comparatively new and show some promise (e.g. [91,92,107], although further rigorous evaluation is required. One advantage of such methods is that other people who are concerned about someone s drinking or drug use could also be involved in treatment even if he/she is not a family member. Finally, interventions that try to alleviate the problems caused to family members by the substance misuse of a relative were discussed There is some evidence that such interventions are very helpful to family members, particularly in terms of reductions in symptoms of stress and ill-health present in family members. Despite the growing body of research studies, however, we still lack a clear direction in terms of what interventions should be used in routine practice. The field is fragmented and it is difficult to compare across studies, given the differences in outcomes measured and the varied range of specific measures used. Most research has relied on quantitative methods with little use of qualitative methodology or attempts to measure treatment process. This, coupled with the lack of a clear conceptual and theoretical basis to some of the approaches, limit our understanding of how these interventions may help family units that include both family members and substance misusers. A further interesting issue is the lack of integration of family member needs in the interventions that are focused upon working with families and users. This is an area for development in future treatment studies. One of the most significant limitations of this treatment literature, however, lies in the fact that most studies have been conducted in specialist research centres in the western world, using approaches that may be difficult to apply in most settings. There are no good examples of pragmatic trials [163] that operate within real-life clinical conditions limiting the clinical representativeness [164] of the studies reviewed. Of great concern, and likely to be related to this issue, is the fact that despite robust evidence, effective family treatments are not implemented in routine practice (e.g. [134,165]. In some treatment systems (e.g. United States) health reimbursement schemes need to recognize family-based intervention before further and broader implementation can occur [166]. Future studies need to address issues of cost effectiveness of the interventions in terms of both the cost of delivering treatments but also decreased future costs to society. The UK Alcohol Treatment Trial has included an element of cost evaluation although when considering families, it is important to acknowledge that there is a broader set of positive outcomes in addition to reductions in substance use. In this context, the potential reduction of social costs associated with the impact of addictions on other family members are important (e.g. substance-related family violence), as well as the reduction of costs associated with resource use through additional health and welfare service demands made by affected family members. Finally, there are important policy implications contained in the research reviewed above. Families are demonstrably important in this area, yet little emphasis is given to them in national and international policy. Although the harm inflicted upon families and children was discussed in the recent English National Alcohol Strategy [2], there were no mentions of family involvement in interventions, either as part of successful treatments for problem drinkers or as needing help in their own right. There are major issues of child protection raised by the large numbers who reside with substance misusing parents, and some of the problems associated with these issues were outlined in the early parts of this review; again, there are policy implications here which need to be grasped (and which have not yet been) in most countries across the world. We conclude that there is a growing evidence base to support family-focused interventions in substance misuse. Although the field remains somewhat fragmented and there is room for much methodological improvement, the evidence strongly supports the notion that family involvement at various points in the treatment process can lead to improved outcomes for both the substance misuser and the family members affected by the substance misuse. Acknowledgements The authors would like to acknowledge Jim Orford for his significant contribution to the programme of work partly described in this review, and to Samantha Hull for her assistance in locating many of the papers cited in the review. References [1] Prime Minister s Strategy Unit. National alcohol harm reduction strategy: interim analysis. London: The Cabinet Office, Available online at: Page4498.asp. [2] Prime Minister s Strategy Unit. Alcohol harm reduction strategy for England. London: The Cabinet Office, Available online at: index.htm or [3] Condon J, Smith N. 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