Velleman R., Orford J., Templeton L. et al.
Addiction Research and Theory: 2011, 19(4), p. 362–374.
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In England a brief primary care counselling programme for family members living with a relative with substance use problems unusually aims primarily to improve the family's lives and coping rather than that of the substance user. Even a year later it seems to have succeeded, and the improvements accumulated rather than faded.
Summary A UK-originated brief counselling programme for family members living with a relative with substance use problems aims primarily to improve the family member's lives and coping rather than that of the substance user. 136 GP practices in the West Midlands and South West regions of England had been randomly allocated to two versions of the programme, which were delivered by 168 specially trained primary care staff. Initially the 143 family members recruited for the trial by the practices were followed up 12 weeks later. At that time interviews repeating baseline assessments found significant reductions in stress and improvements in coping skills, regardless of which version of the programme the practices had been allocated to. The featured report extended the follow-up to a year to test (among other things) whether improvements had been sustained and whether differences had later merged between the impacts of the two versions.
Known as the '5-Step Intervention', the programme guides the primary care clinician to listen (step 1) to the family member, provide information (step 2), help them look at their coping strategies (step 3) and sources of social support (step 4) and explore alternatives, and finally (step 5) to summarise the intervention, assess whether further work is needed, and if so, to refer on to an appropriate service. Normally undertaken in five sessions, the trial tested this implementation against a one-session version. In both the family member was given a self-help manual to aid them in sustaining the strategies introduced and developed during counselling.
Nearly 9 in 10 of the family members recruited for the trial were women. Over the past on average nearly nine years, few had sought help for themselves in relation to what was usually their live-in husband, partner or child, 60% of whom were seen as having a drink problem and the remainder drugs or drink and drugs. When recruited to the study, the family members were usually not attending the surgery for help with coping with their relative, but the need for this help emerged during the consultation or was known to the clinician.
For the 12-month follow-up, extensive efforts resulted in 63% of the family members returning by post a self-completion questionnaire booklet assessing among other things their coping and social support. On all the assessed variables including their initial degrees of distress they were comparable to full starting sample.
As at the 12-week follow-up, there remained no significant differences between those offered the five-session and those offered the one-session programme in their ways of coping Such as engaged, tolerant-inactive and withdrawal coping. with their relatives' substance use, symptoms of stress or distress, and their ratings of the harmful impact of substance problems on the family. However, across both interventions there had been further significant improvements on all these dimensions. Of the 56% who said things were better Another 24% said they were the same and 20% worse. for them now than at the start of the study, nearly two thirds attributed at least some of this improvement to the intervention, but generally they did not see it as highly influential. Improvements were no less among family members who had suffered with their relatives' problems for many years as opposed to a shorter time.
Nearly half (47%) thought their relatives' substance use problems had not improved since the start of the study, yet even these family members had (to a lesser degree than others) experienced continuing significant improvements in their coping and symptoms of stress or distress. However, as opposed to at 12 weeks, by a year there was no longer a statistically significant reduction in their ratings of the degree to which their relatives' substance use problems were harming the family.
Stress and distress were greater and improvements less among parents rather than partners.
Among this sub-sample who seemed representative of the full sample, a year later there remained no differential impact of the abbreviated versus the full programme, but essentially equivalent continued improvements in how well they coped with their relative's substance use problems and in their levels of stress and distress. Most still saw their situations as better than before the interventions, and most of these saw the interventions as partly responsible.
These and other findings from the UK and Italy suggest that this relatively simple and brief intervention enables family members to re-appraise their lives with respect to their substance misusing relative, to see the impact as less of a strain, to revise their ways of coping, and to experience a resulting reduction in stress and distress. Testing the intervention against no intervention would afford a securer indication of the degree to which the improvements were due to the programme or might have happened anyway, but for various reasons Primarily the fact that their situations had on average extended over nine years and yet the family members remained highly distressed before the interventions. it seems likely that the programme did lead to positive change for family members.
From the information gathered it seems unlikely that seeking further help (few did) or following the self-help manual (only a quarter consulted it between the 12-week and one-year follow-ups) provided by the study accounted for the continuing improvements. Instead it seems that the family members – even those with many years of attempting to cope behind them – were empowered themselves to re-appraise the impact their relatives were having on them and the ways they respond, setting in motion a series of appraisals and responses which continued long after the intervention without having to be reinforced by further professional involvement, and even if the relative's substance use problems continued unabated.
However, it is important not to overstate the impact of the intervention. Though there were enduring and accumulating improvements in both coping and stress/distress, the latter remained much higher than in the general population and only fell to levels found among psychiatric patients, while the degree to which the family members had to mount coping strategies remained high. It remains a challenge to develop this or other interventions so that affected family members can reduce their symptom and coping levels even further.
Another implication of the findings is that on the measures taken by the study, the one-session version of the programme is much more cost-effective the five-session version. As a result, an on-line implementation of the abbreviated version has been developed which family members can access directly. As of the beginning of December 2011 it is being re-worked following evaluation and is expected to become active again by mid-2012.
commentary As with alcohol brief interventions in general in primary care, an earlier report from this study makes it clear that despite the offer of funding, it was difficult to find practices and workers willing to take on the family intervention. Among those who initially agreed, more dropped out after being allocated to the longer five-session version, contributing to the fact that almost twice as many family members (92 v. 51) received the shorter version. A previous study in England of the same intervention reported that just 5% of primary care workers took up the offer of being trained in the intervention and under 2% found suitable family members and actually delivered it, an uptake rate far short of the presumed need among their patients. This degree of selectivity of workers and patients raises doubts about whether more comprehensive adoption is possible, and whether if it happened, the results would be the same as in the trials.
For good reasons the authors of the study are convinced that the intervention itself triggered the changes which led to the improvements experienced by the family members. It is hard to believe that simply ignoring their plights would have made as much of a difference as exploring them and suggesting remedies. But the fact that one session of advice was equivalent to an intended five (in practice, typically four) raises the issue of whether a less sophisticated intervention might have worked just as well, such as the GP or nurse merely showing an interest in the family members' predicaments, and turning the consulting spotlight on their needs rather than those of the problem substance user. The very act of being (for baseline assessment purposes) systematically quizzed by the primary care clinician about their ways of coping with problems and the harmful impact of their relative's substance use on them and on the family may have provoked reflection on the need to minimise the damage and cope better. Certainly in studies of brief alcohol interventions focused on the drinker themself, control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. groups exposed to no intentional intervention have sometimes reduced their drinking as much as those exposed to the trialled intervention. In one randomised study of British university students, merely completing the AUDIT questionnaire often used to screen for risky drinking in brief intervention studies was associated with changes in the self-reported degree of hazardous drinking of the same order as when assessment has been followed by brief advice.
Whatever the resolution of that speculation, the study offers hope that paying attention – even briefly – to the problems and stress faced by family members sharing their lives with a problem alcohol or drug user can alleviate that stress, and can do so even if this distressing situation has been going on for many years. In other words, it seems worth primary care staff enquiring in to these issues and offering advice and support. At the very least, systematising that advice and support in to a specific programme should help give staff the confidence to take the first step of asking the questions, knowing they have something in their armoury to respond with if needed, and that those strategies have been associated with some remission in stress in the featured study and others. For more about the programme see this special issue of the journal Drugs: Education, Prevention and Policy devoted to the 5-Step Intervention.
Thanks for their comments on this entry in draft 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 05 December 2011