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Involvement of family members in addiction care

Brendan Flynn
RGN RMN Dip CPN Dip ACC MA
Specialist Nurse Therapist
Couple/Family Therapy Team Coordinator
UKCP Registered Systemic Psychotherapist
Kent and Medway Community Alcohol Service
Canterbury

A multidisciplinary team, led by a specialist nurse therapist, has established a colloborative psychosocial intervention in an NHS adult alcohol treatment setting for couples and families experiencing problems with excessive alcohol use. This project was introduced in response to a national paucity of couple and family-based care and support in alcohol treatment services (ATS).

The initiative actively involves carers, partners, children, relatives and professionals in the drinker's treatment process. The service has been running for seven years and has been increasingly effective in helping drinking clients and family members make significant and sustained change in drinking and related behaviour.

Background
Around 10 million adults in the UK drink more than the government recommends (guidelines state that men should drink no more than 21 units, and women no more than 14 units weekly). Almost 2.6 million adults drink at high-risk harmful levels – that is 1.6 million men (50+ units weekly) and 1 million women (35+ units weekly).1

An estimated 920,000 children in the UK are living in a home where one or both parents misuse alcohol and some 6.2% of adults in the UK have grown up in a family in which one or both parents drank excessively.2

In recent years, a treatment paradox has emerged, with a growing reluctance in ATSs across the UK to provide couple- and family-based clinical interventions, even though evidence-based research increasingly supports the use of interactional couple and family approaches.

In the recent past, addiction problems have generally been viewed from an individual medical or psychiatric dimension and treated accordingly. The social interactional context of drinking behavoiur and the impact on family members of excessive alcohol consumption has been given little attention, and involvement of relatives and others in care provision has been minimal.

According to Fals-Stewart and Birchler, couple and family treatment modalities were seen as "too intensive" and were not typically used as an adjunct to other services, but rather as "a stand-alone intervention".3

A further obstacle was the limited resources available to ATSs in the NHS, which created a culture of prioritising drinker-focused treatments over couple- and family-oriented approaches.

Clinicians' own predispositions also need to be taken into account. Practitioners experiencing anxiety and role insecurity when faced with this client group can be resistant to this style of clinical work, fearing that couples and families will psychologically overwhelm and deskill them.

Client group
The client group seen by the team had generally not responded well to other interventions and could be very resistant to change. They continued to experience escalating degrees of complex needs and harm, and were also reluctant to use professional agencies.

Couples and families had one or more member(s) drinking problematically, with coexisting problems such as mental illness, child/adult protection issues, physical, emotional and sexual abuse, violence and other criminal behaviour. Service users were generally aged between 20 and 60 years; children and other relatives involved in therapy could be of any age.
Couples and family members were mainly white European in origin, while team members represented a range of class, cultures, race and ethnic backgrounds.

The frequency of meetings with service users was influenced by the level of clinical need as well as progress made. Meetings could take place every one to three weeks, and usually lasted for about three to four months. Collaborative reviews of therapy activity took place regularly.

The service
Clients were helped to systemically understand that excessive drinking always occurs in the context of a relationship and can be influenced by family-of-origin dynamics or as part of a restricted communication process in a current relationship. Systemic family therapy helps couples and families to alter, adapt or introduce new beliefs, behaviours and communications that support and maintain change in drinking patterns. The use of systemic therapy with addictive behaviours is a recognised and effective clinical modality.4-7

The service was coordinated by a specialist nurse therapist who was also a trained systemic psychotherapist. The core team included a principal psychotherapist and school liaison officer who were also trained and experienced systemic psychotherapists. The team also regularly had undergraduate, preregistration and postgraduate professionals – counsellors, psychologists, psychotherapists, doctors, social workers and nurses – on supervised placements.

The couple/family therapy team used a range of systemic interventions including:

  • Assessment.
  • Genograms.
  • Circular questions.
  • Hypothesis formation.
  • Interventive interviewing, which uses linear, strategic, circular and reflexive-style questions to facilitate change in cognitions and/or behaviour.

One particular clinical skill the team had introduced and developed extensively was the use of reflecting teams pioneered by Andersen.8

Clinical process
The team comprised five or six people: two members were the therapists who met clients and the remaining members acted as reflecting observers.

"Reflecting teams" embodied a host of principles from the social constructionism paradigm. This paradigm challenges the more traditional forms of social theory and meaning. At the core of social constructionism is the view that there is not a single reality about the world or people's behaviour, but that meaning is pluralistic and socially co-constructed through language. Bateson points out that we learn about ourselves and our relation to others through comparative reflections.9

Comparing what we know against a background of other possibilities allows us to make distinctions. One way of doing this is for couple/family therapy team members to share their views, stories and perspectives with clients as a template for comparison; the team members' reflections may become a background for creating clients' new reflection and understanding of drinking-related difficulties.

It was hoped that, in the context of collaborative and egalitarian relationships, clients would be more likely to be receptive to new ideas and perspectives and thereby feel supported and motivated to risk making changes in the interactional behaviour that influenced and maintained their drinking problems.

The reflecting process allowed clients to listen without having to justify, defend, explain or set the record straight, while knowing there was an opportunity to speak. This provided an unusual space in which new ideas could surface and a different kind of listening and learning took place.

Practice
When therapists met clients, the reflecting team observed the interview from behind a one-way screen in an adjacent room. The reflecting team observers (a maximum of three people) were invited into the room when the therapist and clients agreed that they would like feedback. A conversation took place between team members in the presence of therapists and clients – team members faced each other and did not look directly at clients or therapists. They reflected among themselves clearly so clients could hear what was said. They did this for just a few minutes and then left.

In the remainder of the meeting, therapists invited clients to comment on the team's reflections or to have a "dialogue about the dialogue".8 Feedback from colleagues, service users and evaluation exercises provided several guidelines or principles for the reflecting team.

Reflections can include focusing on problem-creating and problem-dissolving discourse, putting forward alternative explanations of the problem. Introducing possible solutions and hypothetical future scenarios, and exploring family explanations for the problem picture can be helpful.

Emphasising "both-and" rather than "either-or" stories, plus reframing and connoting narrative and behaviour, positively provides relief for some clients.

Practical considerations are important, such as not looking at clients when talking, and leaving them free not to respond to reflections. This can also involve avoiding anything that might make clients feel criticised and not saying too much – there is a limit to what people can absorb.

Outcomes
Evaluation and anecdotal feedback from service users suggests the intervention is effective in promoting interactional change in drinking behaviour. With this in mind, a team member conducted a research project in 2005 on the reflecting-team process. This unpublished research demonstrated that "the scores show a significant positive outcome for couples receiving therapy". After the treatment, clients said:

  • "We feel more confident in managing other problems".
  • "We talk more about different things".
  • "It helped us that our problems were understood from different angles".

More recent evaluation research, commissioned by the team in 2006, confirmed that clients and relatives do find this style of clinical work beneficial and that it improves problem resolution, understanding and communication. This unpublished study demonstrated that 86% of the identified clients made significant changes to their drinking behaviour, and 67% of those with a drinking problem found it beneficial to have their partner who did not drink present at meetings. In addition, 86% of partners who did not drink found it helpful to be involved in the treatment process with their partner who did drink. This collective feedback demonstrates that the postmodernist nature of the reflecting team's approach helps clients to understand their problems as located in linguistic and communication systems.10

Clinical outcome figures for 2007–08 (see Figure 1) reaffirm that involving family and relatives in treatment improves engagement rates. Additionally, improvement in drinking and associated behaviour is also consistent, significant and sustained when employing this intervention.

[[Fig 1 alcohol]]

In 2008, the team won the the Nursing in Practice Mental Health Award and was nominated for other health and social care awards. This acknowledgement has provided a high public and professional profile for the team and our work. Addiction sevices and mental health treatment providers are showing interest in duplicating family-based treatments based on the team's innovation and findings. Therefore, a wider diverse client (and professional) group can benefit from the team's experiences and findings.

One family member said: "The session that my son attended was very positive indeed and he is definitely looking forward to returning. I realise that once a person changes their alcohol consumption, it has a major effect on the family dynamics, but feel that the family therapy is helping us all to work through the changes and I hope that my two younger children will become involved in the future.
"It feels now we have been able to put the past behind us, deal with what is happening in the present and learn to move on from there."

Conclusion
The experience of developing this service helped the team and the ATS to acknowledge that involving partners, children, relatives and friends can have a positive influence on therapeutic engagement and the outcome of interventions. It is clear that the use of couple/family-based intervention has an established and complementary position alongside individual interventions in the mainstream treatment of excessive drinking and related difficulties in ATSs.

The involvement of family members in treatment activities is clearly effective in addiction management agencies and has the potential to be usefully applied in nonaddiction health and social care contexts where behaviour is of serious concern.

References
1. NHS Information Centre. Statistics on Alcohol, England, 2008. London: NHS Information Centre; 2008. Available from: http://www.ic.nhs.uk/webfiles/publications/alcoholeng2008/Statistics%20o...
2. Alcohol Concern. Alcohol and the Family: A Position Paper from Alcohol Concern. London: Alcohol Concern; 2008.
3. Fals-Stewart W, Birchler GR. A national survey of the use of couples therapy in substance misuse treatment. J Subst Abuse Treat 2001;20(4):277–83.
4. Carr A. The effectiveness of family therapy and systemic interventions for adult-focused problems. Journal of Family Therapy 2009;31:46-74.
5. Copello AG, Velleman RD, Templeton LJ. Family interventions in the treatment of alcohol and drug problems. Drug Alcohol Rev 2005;24:369-85.
6. Meads C, Ting S, Dretzke J, Bayliss S. A systematic review of the clinical and cost-effectiveness of psychological therapy involving family and friends in alcohol misuse or dependence. A West Midlands Health Technology Assessment Collaboration Report. Birmingham: University of Birmingham; 2007. Available from: http://www.rep.bham.ac.uk/2007/FamilyTherapy.pdf
7. Stratton P. Report on the Evidence Base of Systemic Family Therapy. Warrington: Association for Family Therapy; 2006.
8. Andersen T. The Reflecting Team: Dialogues and Dialogues about the Dialogues. New York: Norton; 1991.
9. Bateson G. Steps to an Ecology of Mind. New York: Ballantine; 1972.
10. Anderson H, Goolishian HA. Human systems as linguistic systems: preliminary and evolving ideas about the implications for clinical theory. Fam Process 1988;27(4):371–93.