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Focus on the families

This Hot Topic explores interventions with families affected by substance use. Documents retrieved by this search focus primarily on the welfare of the families themselves, but will include some on family therapies promoting the welfare of the problem user. For more on this last issue, try this search instead.

The forgotten carers

There is growing evidence that supporting the relatives of people affected by substance use can bring huge benefits to the whole family, as well as bringing potential cost-savings to services. Interventions targeting family members’ own needs can result in increased resilience, life satisfaction and relationship satisfaction, decreased stress and distress, and benefits for the people around them, including children and relatives with substance use problems.

Despite this promising evidence, there is a lack of recognition of adult family members’ support needs in drug and alcohol policy and guidance. In 2012, the UK Drug Policy Commission produced a report highlighting this gap, and recommending more assertive promotion of help for adult relatives in primary care settings, and routine assessment of their needs when relatives with substance use problems engage with treatment.

Two British studies have explored the feasibility of a short intervention with relatives in a primary care setting. The first study gathered the views of 27 patients who had participated in up to five sessions with a primary health care worker. These patients reported that after the intervention, they relied less on unhealthy coping strategies and felt physically and psychologically better. This study evolved into a second larger study involving 136 GP practices in England. Patients were allocated to one of two groups this time, one offering five sessions, and the other offering a single session. There were no significant differences between the groups. Instead, across both groups there were significant improvements on all the assessed outcomes. In the studies above, it proved very challenging to engage primary health care workers and GP practices, despite the offer of funding. This raises some doubts about how successfully an intervention of this kind could be rolled out across the UK. Incorporating substance-related questions within general health screening for the adult relatives of people with substance use problems may be a more acceptable strategy.

Families with multiple support needs

The two studies above describe interventions with adult relatives – considering how the substance use of someone close might be affecting them, and what support they might need in their own right. However, most studies in the field of family interventions focus on protecting the welfare of children and families where it is the parent or carer who has a substance use issue. Such families may have multiple support needs, and may already be known to multiple agencies.

Scottish approaches for engaging families prioritise child well-being, prevention, resilience, recovery and long-term change. In 2012, Getting Our Priorities Right outlined practice guidance for child and adult service practitioners working with children, young people and families where problematic substance use is a factor. Key principles of this are a ‘whole family’ approach for assessing need, and early intervention activities, “working together effectively at the earliest stages to help children and families and not waiting for crises – or tragedies – to occur”.

The Australian Institute of Family Studies has reviewed literature on the outcomes of children raised in families with multiple problems including parental substance misuse. It notes the ‘risk factors’ for children living in families affected by substance use, but adds that interventions which aim to build on parental strengths produce ‘protective factors’, helping to mitigate against those risks for children. It argues that another crucial consideration in treatment approaches should be the wider social environment, in which poor housing, unemployment and social isolation influence outcomes for children. They conclude by saying that “families will fare best when they are engaged in the process of treatment, feel a part of the treatment, have a commitment to the treatment and hold the view that they are working with the service to achieve common goals”.

Engagement in treatment was explored in the following reflection on a pilot study in Scotland. Though contact might be initiated against parents’ wishes and proactive monitoring is essential, the authors advised that successful early intervention with families is reliant on generating their voluntary participation, and requires close attention to means of facilitating positive and motivated parental engagement. Interventions with families have typically been characterised by the central aim of monitoring child welfare. Fearful of the consequences of the ‘enquiring gaze’ of social services, parents may resist meaningful engagement. This particular study explored resistance in the context of six families affected by substance use, defined as in need of supportive intervention. The authors suggest that resistance may be overcome through improving the way that services communicate with families, and “exploration of the possibility of putting some distance between the offer of support and an often all too close link with the threat of punitive action”.

The Australian National Council on Drugs (ANCD) commissioned a review of policy in relation to child- and family-sensitive practice in Australia. The report references a workforce development guide, describing child- and family-sensitive practice as “raising awareness of the impact of substance abuse upon families, addressing the needs of families, and seeing the family – rather than an individual adult or child – as the unit of intervention”.

Option 2 was a crisis intervention service, funded by the Welsh Assembly, designed to view the family as the unit of the intervention. Specifically, it focussed on working with high-risk families, where there were serious child protection concerns related to parental substance use. The intervention lasted four to six weeks, and used a combination of motivational interviewing and solution-focused counselling styles. An early evaluation of the service found that families liked the service and that it reduced the need for children to enter care, thus generating significant cost savings for local authorities. A subsequent evaluation confirmed that this model significantly reduces the need for children to enter care, is likely to generate very significant cost savings for local authorities and other social care, health and criminal justice agencies, appears to be an effective way of engaging and helping parents with serious drug and alcohol problems to significantly reduce their drug or alcohol use, and overall, improved family wellbeing and parental welfare.

Keeping families together

The family drug and alcohol court is an intervention approach which can help parents to address their substance use support needs, with the overarching goal of creating a stable environment for children which would enable the family to safely stay together. Unlike traditional family courts, they have a team of experts from substance use and child welfare, aligning the treatment goals and philosophies of both sectors. There are several open in England, including London, Gloucestershire and Milton Keynes, and more were due to open in East Sussex, Kent and Medway, Plymouth, Torbay and Exeter, and West Yorkshire following a funding announcement from the Department for Education. A pilot study of family drug and alcohol courts in London suggested that compared to ordinary care proceedings, they produce better parental and child outcomes at a lower cost.

Similarly, the US Engaging Moms Program aimed to support mothers facing loss of custody of their children get to the point where they could be reunited with their children. It helped them to comply with court orders, engage with substance use treatment and develop their parenting skills. A small-scale study compared the effectiveness of this with traditional case management (coordination of services). More mothers in the Engaging Moms group retained their parental rights and completed the drug court programme, compared with the other group. In addition, at the three-month follow-up, participants with Engaging Moms reported significantly stronger therapeutic relationships with their counsellors, a factor known to facilitate ongoing engagement with treatment.

A strong therapeutic relationship is often cited as an important platform for successful intervention, as is a programme tailored to the needs of the client. This United States-focussed progress review advocates integration at the service delivery level through comprehensive assessment which documents all the client’s co-occurring health and social problems and systematically matches service needs to problems in the context of a positive client-provider relationship.

Programmes which integrate addiction treatment with on-site pregnancy, parenting, or child-related services typically provide individual addiction treatment, maternal mental health services, trauma treatment, parenting education and counselling, life skills training, prenatal education, medical and nutrition services, education and employment assistance, childcare, social services, and aftercare. This pilot trial integrated residential substance use treatment with a brief (10 sessions) yet intensive attachment-based parenting programme for new mothers. Subsequent observations of the parent and child together revealed more supportive and sensitive parenting behaviours. Few systematic reviews have been conducted to assess whether integrated services improve parenting outcomes. However, the limited evidence suggests that integrated services may provide small improvements in parenting. Though by no means a spectacular result, for high-risk families this may have the knock-on impacts of reducing the need for foster care and improving the wellbeing of children.

Family conflict

Disagreement and conflict is common in families, and may at times be exacerbated in families dealing with substance use. However, a research report from Adfam (UK national charity working to improve life for families affected by drugs and alcohol) stressed that professionals should know and feel confident enough to distinguish family conflict from domestic abuse, and the risks of assuming either will automatically be alleviated when substance use problems are resolved. The report also raises an important question about the extent to which services built around keeping parents and families together, or seeing the family as the ‘unit’ of the intervention, are conducive to vulnerable people making disclosures, or talking about domestic abuse.

Run this search for more on protecting and improving life for the families of problem substance users, or instead this search for information on interventions with families aimed at helping a relative with substance use problems.

Thanks for their comments on the original entry to Richard Velleman of the University of Bath and Jamie Pennycott of Southend’s Drug and Alcohol Team in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 13 November 2015. First uploaded 01 September 2010

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