Scottish Government

Effective Interventions Unit Supporting families and carers of drug users: A review

CHAPTER 5: METHODS OF SUPPORTING FAMILIES AND CARERS

This Chapter examines and discusses the variety of methods of supporting families, coping with a relative's drug use. Evidence has been drawn from the literature review, the mapping exercise and the qualitative study. It also incorporates views from the EIU interviews and the Family Support Conference survey. It sets out:

• methods of support
• the aim of these support interventions
• examples of methods

Although there is a wide range of types of interventions to support families theoretically, the extent to which these interventions are available in Scotland varies considerably from area to area. This was demonstrated in the EIU mapping exercise. Overall, there was limited availability of intensive types of support such as family therapy and counselling and where these were available they were often oversubscribed.

Methods of Support

There appears to be evidence that there are particular benefits from certain types of support. In the EIU literature review, a study by Toseland compared the benefits of group support interventions with those of individual interventions. Both types of intervention aimed to provide:

• validation of care giving experience
• encouragement and care
• reassurance about coping
• support in managing difficult situations

The findings were that both types of intervention were beneficial to participants but:

• more formal, informal and social support was gained from groups
• individual interventions were more problem orientated and allowed the individual to explore a wider range of personal issues

The evidence shows that different types of interventions have different benefits. It also suggests that different types of interventions can complement each other. Individual interventions e.g. one-to-one support or counselling, may be more appropriate and effective at early stages of contact. The aim might then be to support the individual to move on to participate in group methods of support, such as family support groups.

1. Family Therapy

Family therapy is an approach that aims to assist people experiencing difficulties in their own lives and their family lives. The Association for Family Therapy and Systematic Practice in the UK state that family therapy is based upon the idea that:

'the behaviour of individuals and families is influenced and maintained by the way other individuals and systems interact with them. This way of working involves engaging with the whole family system as a functioning unit'.

Family therapy can be delivered on a one-one basis or within a group work setting.

There is a diverse range of family therapies in existence. In relation to substance addiction, many of these have been used in the field of alcohol misuse and have focused upon the key outcome of altering the behaviour of the drinker. Family therapy is now being used to work with families affected by drug use and there is some evidence of effectiveness in relation to the drug user: for example, reducing drug use; reducing psychological harm; reducing social problems (Drug Treatment for Young People Research Review, EIU 2002). Recent developments have seen family therapy interventions that focus primarily on addressing the stress experienced by family members (Copello, Velleman et al, 2002).

We set out below a number of types of family therapy that have been subject to evaluation. Further information can be found in the EIU literature review ( EIU 2002).

Community reinforcement training (CRAFT)

CRAFT was originally developed in working with the partners of problem drinkers although has been widened out within the field of substance addiction. CRAFT training can occur on a one-to-one basis and within a group setting. Support is offered on the expectation that the family member will play a significant role in the treatment and support of the substance user and secondly, that it will bring benefit to the family. It does not assume that the concerned significant other (CSO) is in any way responsible for the drinking or drug problem of the loved one.

The key elements are:

• understanding that responsibility for the problem belongs to the drinker
• motivating the partner
• improving communication
• using positive reinforcement
• reducing behaviour by the partner that inhibits the drinker from acknowledging the action and consequences of their drinking
• the process encourages the concerned significant other to consider their own needs rather than solely that of the substance user to improve their own well being and stress
• broadening their social activities
• taking time away from the substance user
• getting space away from the pressures associated with coping with substance use

In the EIU literature review, a study by Kirby et al investigated individual and group counselling methods of delivering 'Community Reinforcement Training' (CRAFT). They found that the CRAFT intervention:

• reduced the number of self-reported problems of family members, particularly relating to areas of finance
• improved mood states
• increased social functioning and family functioning
• self-esteem did improve but not significantly
• the drug user was more likely to enter treatment

For further information on CRAFT see: http://casaa.unm.edu/bib/cra.html

Unilateral family therapy (UFT)

Again this approach was developed to work with partners of alcoholics to encourage the drinker to enter treatment and has been widened out to work with drug users. It has a similar approach to CRAFT in that the therapist meets with the partner over a period of months and aims to: address how the partner copes with the impact of substance use; reduce the level of substance use; and engage the substance user in treatment

The partner goes through a series of modules aimed at addressing:

• the severity and impact of substance use
• ways of enhancing the relationship
• constructing obstacles to reduce opportunity for using substances
• counter productive responses
• improving the wellbeing of self and other family members

On completion of the modules the aim is for the partner to encourage the substance user to engage in treatment.

Research concentrated on outcomes associated with the substance user and not on the family member/partner. Studies found that 61% of drinkers whose partners were involved within UFT engaged in treatment compared to none of the drinkers whose partners had no UFT. The 'wellbeing' of the partner was not reported on (EIU literature review).

Pressures to change

This intervention again focuses on using the partner as a catalyst to engaging the substance user in treatment. The partner attends one to six sessions based on:

• providing information regarding the 'change' process
• planning activities that make it hard to use substances
• how to respond: assisting the partner to identify acceptable and unacceptable levels of substance use; encouraging abstinence; encouraging and supporting substance user to seek support
• contracting and boundary setting
• involving others to support process

In the EIU literature review, a study by Barber & Gilbertson into the Pressures for Change process looked at three groups of partners: those engaged in counselling; those engaged in group work; and those on a waiting list. They also compared the study with a group engaged within Al-Anon. Results indicated that those engaged in individual counselling and Al-Anon reported a reduction in the level of personal problems they experienced. A self-help manual was later developed and this was found to have a similar impact as that of counselling.

Stress-coping-support model

This intervention developed by Birmingham and Bath University is currently being piloted in England with primary health care workers and general practitioners and complements previous work conducted by them on coping mechanisms. This research is linked to a larger research exercise by the World Health Organisation investigating the role of primary health care workers in supporting families coping with addiction.

The primary aim of the work in comparison with previous models of therapeutic intervention is to support the 'family' in their own right rather than to engage the relative in treatment, although that may be a secondary outcome.

Orford et al has developed three broad definitions of methods that people use in coping with someone's drug use (1998).

The 'Tolerant' approach

This approach relates to where the family is tolerant of the drug use and the associated behaviour of the drug user. Examples of this approach include turning a blind eye to drug use, clearing up after the drug user and lending money to the drug user even though you suspect it may be to buy drugs. Orford indicates that this form of coping is associated with feelings of worry, guilt and powerlessness.

This form of coping rarely effects any change in the drug use although a form of stability may be maintained within the family by reducing the occasions of conflict.

The 'Engaged' method

Families that use an 'engaged' method of coping are often attempting to change the behaviour of the drug user and supporting them in addressing their drug use. Examples include organising treatment appointments for the drug user, checking up on their every move, being supportive and defending the drug user, encouraging and rewarding the drug user. Orford suggests that this method can be of benefit to the family in that they feel a degree of power and involvement, they are being positively supportive, and they are able to display emotion within the family.

This style of coping is driven by the desire to resolve the problem but can be very stressful due to the energy and perseverance often required from the family.

The 'Withdrawal' model

This approach is related to the family withdrawing from the relationship they have with the drug user. Examples of this include avoiding the drug user as much as possible, making the drug user tidy their own "mess" and not rescuing the drug user from situations of their own making. Orford suggests that this method of coping can allow the family to feel greater control and independence over one's own life.

The main feature of 'withdrawal' as a model of coping, in contrast to the 'engaged' or 'tolerant' approach, is that it focuses upon the family rather than the drug user. However, it may also be of benefit to the drug user in that by taking responsibility for their circumstances they are more likely to address their drug use.

All of the above methods of coping can produce positive and negative outcomes for the relative and can also generate uncertainty for the relative over the best ways of coping. From this the researchers were able to construct a 'Stress-Coping-Health Model' (SCHM), and develop an intervention package for primary health care workers and general practitioners.

The key concepts associated with the use of SCHM are based on five strategies:

• listen, reassure, explore concerns
• get to know the relative and the problem- identifying stresses and strains
• provide relevant information- an important contributor to stress is the lack of accurate knowledge about alcohol/drugs, their effects and issues of dependence. Information should be targeted and not overwhelm the client
• counselling about coping - focusing on the actions and feelings of family members; and about social support- the level of social support available to relatives can have a significant impact on their ability to cope and their experienced stress
• discuss needs for other sources of specialist help - professionals should be familiar with what services are available locally and the appropriateness of them when referring either relative or drug user

These concepts became the basis of developing a Training Manual for primary health care workers to use when engaging with families affected by addiction.

The research trials and analysis should be completed by the end of 2002, at which stage the findings will be disseminated and methods of marketing the training package will be identified. The picture emerging is very positive with almost all relatives reporting great benefits from practitioner intervention, and a slightly less positive response from those using the 'self-help' model.

Further information can be obtained from: Alex Copello, Consultant Clinical Psychologist, Birmingham University a.g.copello@bham.ac.uk

Resources:

Institute of Family Therapy - The Institute offers a wide range of training courses, clinical services, mediation service and consultation.
020 7391 9150
http://www.instituteoffamilytherapy.org.uk/index.htm

Association for Family Therapy and Systematic Practice in the UK (AFT): A main aim of the organisation is to develop practice and standards for training within family therapy. It looks to promote best practice in training, practice, management and research.
Contact: 01925 444414
http://www.aft.org.uk/mainpages/jft.html

2. Counselling

Counselling is similar to family therapy in that the individual is encouraged to explore their concerns and issues in a safe environment, and to examine ways of managing these in a more beneficial manner. Counselling can include work with an individual, couples or groups of people. It can be carried out over a short period of sessions or for a significant period of time.

The British Association of Counselling and Psychotherapy states that counselling may be address:

• developmental issues for the individual
• resolving specific problems
• making decisions
• coping with crisis
• developing personal insight and knowledge
• working through feelings of inner conflict
• improving relationships with others

There are a variety of counselling approaches such as psychotherapeutic, cognitive behaviour therapy and person centred/humanist. Individuals may find one approach is more suited to them than another approach or that it compliments other support they are receiving.

Participants in the EIU conference survey identified counselling as a key method of providing emotional support to family members.

It is important to note that there is no requirement at present for a person to have a specific counselling qualification in order to practice. At present anyone can call themselves a counsellor without any qualification or experience. This has the risk that untrained people can be delivering support that may be counterproductive and damaging to the individual. It is important that people providing counselling or using counselling skills have the appropriate training and are supported in their work.

Provision of counselling for families coping with a relative's drug use is limited within Scotland. In the EIU mapping exercise, 37 family support groups and 39 drug services stated that they offered counselling to families. Where there was such provision it was often oversubscribed and under- resourced for the demand. In Glasgow there was one counsellor attached to the Glasgow Association of Family Support Groups. The service was 'stretched to the limit', but it highlighted a significant benefit in that it could attract people who may not have attended a support group. Some support groups were able to offer access to counselling within other agencies, such as Carer organisations.

Resources:

Counselling and Psychopherapy in Scotland (COSCA) supports and promotes good practice in counselling and the use of counselling skills throughout Scotland. COSCA facilitates preparation for appropriate professional regulations, develops and supports high standards of competence in counselling training and practice covering counselling and counselling skills.
Contact: 01786 475140
www.cosca.org.uk

The British Association of Counselling and Psychotherapy(BACP): BACP aims to provide a complete reference point for anyone seeking information on counselling and psychotherapy in the UK. It provides nationally recognised standards in training and practice, and training within counselling and psychotherapy.
Contact: 0870 443 5174
www.bac.co.uk

3. Parenting Skills

Some statutory and voluntary sector agencies provide assistance for parents where there are difficulties with the behaviour and drug use of a child. Often this is carried out through Social work departments and voluntary agencies such as Barnardo's and Save the Children. This process aims to engage the whole family in altering dynamics in the family that can also assist the young person to change or modify their behaviour.

The content involved of such courses can include:

• assertiveness training
• crisis intervention
• themes in adolescent behaviour
• communication skills
• knowledge of resources and support

A main aim of the process is to bring parents together who are experiencing similar issues and difficulties to share experience and learn new skills in coping with the behaviour of their child.

Resources:

Parent Network Scotland (PNS) is a registered charity based in Aberdeen. It is a parent run organisation providing education and support to help improve their parenting, communication and relationship skills.
Contact: 01224 867951

Parentline Plus offers help and information parents and families. The organisation works with local and central government to develop initiatives that increase support for families. It works to ensure that families have access to good quality support and information on issues they face.
Contact: 020 7284 5500

4. Telephone Helplines

There are a number of telephone helplines now in existence. They cover a wide range of subject matter, including drugs. Some have a national remit, such as Childline, whereas others provide a more locally based service. Details of helplines are set out in Chapter 9.

Helplines aim to provide accurate information and support to the caller, using a counselling skills approach. It is important to give careful consideration to the structure and operation of helplines to maintain standards, quality and consistency of the service.

The key advantages of helplines are that:

• they are accessible for people who may not be able to visit a centre based service
• there is anonymity for the caller
• there are no transport or childcare difficulties

Disadvantages can be:

• they tend to be used only at times of crisis - can mean that the helpline feels underused, especially if operational 24 hours a day
• such services can require substantial resources e.g. costs of training, publicity
• requires access to a telephone by the individual

The EIU conference survey indicated that 'helplines' were a popular source of support for families, especially when staffed by those who had experience of living with drug use. There were some concerns, however, that callers were not always listened to or given relevant information.

From the EIU mapping exercise, over one third offered some type of helpline service. This could vary from a group member providing 24 hour support from their own home to members staffing a phone in an office environment for a limited amount of hours.

Local helplines offer a greater awareness of the services and resources that exist locally and people also feel there is a local familiarity.

An important issue to be considered is that, like counselling, there can be a wide variance of standards of practice and the quality of helplines can differ. Those offering support via a helpline should ensure there is consistency of practice, this is best achieved through the delivery of appropriate training.

Resources

Telephone Helpline Association (THA)provides advice, consultancy and training on establishing and maintaining helplines. Members of the THA include Childline and the Samaritans. They also provide publications such as a Quality Standards Workbook and a Helpline Directory
Contact: 0141 221 1514
www.helplines.org.uk

PADA - as well as operating a UK wide 24 hour helpline service, PADA provide training to family support groups and others in establishing a helpline service. (a full description of the range of work PADA do is contained in Chapter 9)
Contact: 0151 356 1996 / 08457 023867 (helpline)
www.pada.org.uk

5. Respite

It is increasingly being recognised that respite provides a useful method of support to families affected through drug use. This is especially the case when grandparents or other relatives take on the parenting role of children whose parents are drug users. Several groups and agencies provide a range of respite models.

Respite can be delivered in a variety of ways:

• centre based respite - where either the carer or dependant attends activities provided for them
• family based respite - this can allow the carer time away from the house without the dependant who is looked after by a worker or volunteer. This can be for a short period of time or longer periods such as a weekend
• home based respite - this is where the dependant is taken away from the house for a period of time to allow the carer some time for themselves or other family members
• holiday based respite - this is provided to give families a break from their environment, which they could not otherwise obtain

Twenty percent of family support groups involved in the EIU mapping exercise offered some form of respite. It can also be provided by more generic based projects that work with families in various circumstances. This can have advantages in that the family support group does not have to acquire the resources and skills to manage such a service if it can link with the work of other more generic projects.

Resources

The Scottish Executive has published material looking at national care standards within the provision of respite care services. The document provides a useful resource for those considering providing respite provision.
http://www.scotland.gov.uk/library3/social/ncssbrc-00.asp

6. Advocacy

Advocacy can be defined as giving protection to people who are vulnerable and discriminated against by assisting them to access their rights. It is also about empowering people to express their own needs and make their own decisions.('Advocacy: A guide to good practice' (Scottish Health Advisory Service, Scottish Office 1997)

Advocacy is recognised as an important method of enabling people to make informed choices and have a degree of control over the issue they are experiencing difficulty with. It has recently started to gain greater prominence for issues relating to drug users' rights of access to treatment and support. Chapter 4 describes how those taking on carer roles can often experience difficulties in dealing with agencies such as the NHS, Benefits Agency and education services. This experience, along with the self blame and guilt that families can feel, can result in them having little energy or confidence in challenging decisions or systems.

There can also be personal benefits to be gained from receiving advocacy support. The experience can be an empowering one for the person concerned, in that they can develop skills of assertiveness and also increase their self confidence. This in turn can mean the individual is better equipped to cope with stressful situations.

Many support groups offer forms of advocacy. A third of respondents in the EIU mapping exercise stated that they offered advocacy support. Advocacy work should be structured and there should be policies and guidelines in place to ensure good practice and consistency.

Resources:

Assistance and copies of guidance in relation to establishing and operating an advocacy system are available from the:

Advocacy Safeguards Agency - Tel 0131 538 7717 Email general@shstrust.org.uk

Scottish Action on Substance (SAS) - 123 West Street, Glasgow. G5 8BA

7. Befriending and Peer support

Befriending offers a supportive and consistent relationship to individuals who may experience isolation and exclusion from the wider community. Often befriending is provided by volunteers and has been used extensively in the areas of mental health, disability, children and families and social exclusion.

Family members say that being able to share experiences with someone with similar experiences can be beneficial. It can allow them to feel safe to explore in-depth some of the feelings and emotions they experience.

The 'Home-start' model of befriending could be of benefit in reducing the isolation of family members especially those taking on the care of dependent children.

To be successful it is necessary for befriending to be a positive experience for the person giving and the person receiving the service. Befriending should also be well thought out and clearly structured. It should have policies and guidelines in place to ensure consistent standards of practice. Assistance may be available from local agencies such as the local Volunteer Centre and national organisations such as Befriending Network Scotland.

Resources:

Befriending Network Scotland: BNS acts as an umbrella organisation for for befriending projects in Scotland and works to promote the value of befriending as a means of support to individuals. They provide information, training and support which aims to assist projects in developing best practice.
Contact: 0131 225 6156
www.befriending.co.uk

Home-start
Contact: 0800 68 63 68
www.home-start.org.uk

8. Developing personal coping skills

There are a variety of methods of supporting family members and carers to develop their personal coping skills. Stress and anxiety are significant factors for families coping with drug use. It has a considerable impact on both the physical and psychological health of the person.

Stress management is the ability of an individual to manage the perceived pressures they face on a day to day basis. This may be through a variety of techniques including reducing or re-appraising the pressures and enhancing coping ability and resources.

(International Stress Management Association UK)

Some of the most common signs of stress are :

• Mood swings
• Anxiety
• Skin problems
• Tiredness
• Muscle tension
• Poor concentration
• Changes in sleep patterns
• Changes in eating patterns
• Low self esteem
• Poor memory

It is very important to take positive action when faced with stress as, if experienced over a period of time, it can seriously impair mental and physical health

Participants in The EIU qualitative study identified that the ability to manage stress better and learning to be more assertive would assist them in coping with their situations. It would also assist them to maintain and develop their self-confidence.

Other methods of coping with stress include complementary therapies. There is a wide range of complementary therapies available. Some can be quite intense and require a degree of effort such as types of yoga. Others are very easy to gain benefit from and require little from the individual apart from the ability to give it a try. Such activities as reiki, relaxation and breathing exercises can be done by anyone regardless of their fitness. It is important to ensure that, if therapies are being done in a group setting, the activity is suitable for all participants.

Many family support groups have used different therapies either as one off events with members, as part of their regular meetings, or have completed training to deliver specific therapies.

Other complementary therapies include

• Breathing Exercises
• Tai chi
• Yoga
• Auricular acupuncture
• Massage
• Reiki
• Aromatherapy
• Reflexology

Resources:

International Stress Management Association (UK): Aims to promote sound knowledge and best practice in the prevention and reduction of human stress
Contact: 0700 780430
www.isma.org.uk

9. Diversionary activities

There are a wide range of diversionary activities that can benefit family members and carers. They can be a useful method of supporting siblings, who can often become withdrawn and isolated (EIU literature review). Activities can provide an escape from the circumstances that families and carers live with. In turn this can reduce their stress for a period of time but that alone can be of value.

Other examples of diversionary activities include:

• activity based work such as drama, music, photography etc
• outdoor activities and sports
• trips and visits

10. Education and information

For families coping with a relative's drug use, trying to understand what is happening and why, is one of the most challenging tasks they initially face. The person they previously knew may have changed dramatically in terms of their physical appearance and in their personality.

Initially, families' knowledge and understanding of drugs and addiction can be limited. Much of their knowledge may come such sources as the media. This information can often have a very negative perspective and also lack accuracy, both of which are unhelpful to families affected by a relative's drug use.

Much of the emphasis on the production of drugs information and education focuses upon information for parents informing them about the general effects of drugs and what they can do as a parent to prevent or reduce the risk of their child using drugs. Families coping with drug use require information and education specific to their situation to assist them in making sense of their circumstances. To date the provision of such information has been limited and accessing such information can prove difficult.

EIU interviews with those working with parents constantly stated that lack of information inhibited the parents and family from being able to best cope and manage their family circumstances. There was also a need for agencies and workers to have access to information and education. This would help them to gain a better understanding of the effects of problem drug use upon family members.

Other relevant information that can assist families and carers include:

• Health issues
• Legal issues
• Rights of families as carers etc
• Methods of coping
• Other support available

Information can be delivered in a number of formats:

• Written information
• Verbal information
• One-one setting
• Group settings
• Video
• Internet

Information should be available in a variety of formats. It is also beneficial if families can access information supported by discussion to assist and clarify understanding.

Internet / world wide web

There is a growing body of information available through the internet. This has the advantage that:

• an individual can access the information at any time and when it is suitable to them
• anonymity of the individual is maintained
• easy to update with new information

The main disadvantage of the internet as a source of information is that there is no guarantee as to the quality of the information. Information can be unhelpful in that it can give biased opinion and misinformation. It is also reliant on families having access to a computer which is something that should not be taken for granted by agencies. There are a number of websites been developed which focus specifically on supporting families. Examples of these can be found internationally and nationally. These sites are useful for individual family members as well as support groups in that they can provide useful links, ideas and information.

A comprehensive description of available information is provided in Chapter 9.