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The relative efficacy of two levels of a primary care intervention for family members affected by the addiction problem of a close relative: a randomized trial

Alex Copello, Lorna Templeton, Jim Orford, Richard Velleman, Asmita Patel, Laurence Moore, John MacLeod & Christine Godfrey.

School of Psychology, University of Birmingham and Substance Misuse Services, Birmingham and Solihull Mental Health Trust,1 Mental Health Research and Development Unit, University of Bath and Avon and Wiltshire Mental Health Partnership NHS Trust,2 Cardiff Institute of Society, Health and Ethics, Cardiff University,3 Department of Social Medicine, University of Bristol4 and Department of Health Sciences, University of York, York, UK5

Objectives: A randomized trial to compare two levels of an intervention (full versus brief) for use by primary healthcare professionals with family members affected by the problematic drug or alcohol use of a close relative.

Design: A prospective cluster randomized comparative trial of the two interventions.

Setting: A total of 136 primary care practices in two study areas within the West Midlands and the South West regions of England.

Participants: A total of 143 family members affected by the alcohol or drug problem of a relative were recruited into the study by primary health-care professionals. All recruited family members were seen on at least one occasion by the professional delivering the intervention and 129 (90 %) were followed-up at 12 weeks.

Main outcome measures: Two validated and standardized self-completion questionnaires measuring physical and psychological symptoms of stress (Symptom Rating Test) and behavioural coping (Coping Questionnaire) experienced by the family members. It was predicted that the full intervention would show increased reduction in both symptoms and coping when compared to the brief intervention.

Results: The primary analysis adjusted for clustering, baseline symptoms and stratifying variables (location and professional group) showed that there were no significant differences between the two trial arms. The symptom score at follow-up was 0.23 [95% confidence interval (CI): -3.65, +4.06] higher in the full intervention arm than in the brief intervention arm, and the coping score at follow-up was 0.12 (95% CI: -5.12, +5.36) higher in the full intervention arm than in the brief intervention arm. Conclusions A well-constructed self-help manual delivered by a primary care professional may be as effective for family members as several face-to-face sessions with the professional.

Keywords: Alcohol and drug problems, family members, primary care, randomized trial, stress and coping.

Correspondence to: Professor Alex Copello, School of Psychology, The University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. E-mail: a.g.copello@bham.ac.uk

Submitted 31 October 2006; initial review completed 2 February 2007; final version accepted 6 October 2008

Addiction and the family: is it time for services to take notice of the evidence?

Working with family members in specialist drug and alcohol services: Findings from a feasibility study:

Avon and Wiltshire Mental Health, Partnership NHS Trust and the University of Bath, UK

Background: Family members can be affected by a relative’s substance misuse, but service provision is limited. A brief intervention in primary care has been shown to be effective. The application of such an intervention in other settings requires investigation.

Aims: To assess the feasibility of the development and implementation of a brief intervention for family members of substance misusers, within Specialist Drug and Alcohol Services.

Findings: Thirteen staff, from seven teams across one Mental Health NHS Trust area, worked with twenty family members. It was shown that it was feasible to: adapt the intervention for use within a specialist setting; recruit and train specialist service staff to deliver the intervention; have these staff recruit and work with family members; and for this intervention to be seen by both staff and family members as a positive and useful addition to service delivery. However, although feasible, there are still difficulties in integrating this work into routine clinical practice.

Conclusions: It is feasible, and beneficial, for specialist drug and alcohol services to deliver a brief intervention to family members. However, organizational and commissioning issues mean that routine delivery of such an intervention may not yet be possible, until full recognition is given to the view that addiction problems are best dealt with in a more holistic way that takes into account the family context within which most people live.

The study examined the grief experience of parents of adult children with problematic drug use, and its relationship to parental health and well-being, parent-child attachment and family communication. 49 parents (42 mothers and seven fathers), completed self-report measures of grief, health status, parent-child attachment and family communication. Participants reported experiencing grief in relation to their adult child's substance use problem as evidenced by cognitive intrusions, avoidance behavior and emotional distress. Increased parental grief was associated with reduced well-being and insecure parent-child relationship while greater cohesiveness in families was associated with lower levels of parental grief. The study provides valuable insights into grief experiences of parents of adult children with problem substance use. There is a clear need for parents to have their distress and grief acknowledged and validated and a need for interventions that promote grief work and facilitate family coping.

Ease of access to information and support

As shown by the numbers of family members who contact the ADF, there is a huge demand for information and support from the community. However, a common complaint from families is that they find it difficult or confusing to know where to go to for assistance. This is particularly true when they are seeking to access treatment, other intervention or support services.

Not all situations require the same response and many families need a range of services from different disciplines. Lack of identifiable services is a source of frustration to many. Many family members have been on a merry-go-round of services before they find the information and support best suited to them.

While most states and territories have systems in place for drug users, the needs of families have not always been serviced. The tendency to focus on the drug user and interventions relating to the drug user has resulted in a lack of acknowledgment of the impact drug use has on all family members and the significant role families play in drug treatment and support.

A centralised information system is required to assist families to identify the type of service(s) they require and what is available in their locality or region. A centralised, ‘one-stop-shop' service for families could offer a comprehensive range of support services including telephone, website and on-line networks (for example, online counselling, chat groups, question and answer forums etc).

Family orientated services

Increased access is needed to programs specifically set up to service the needs of families of drug users, rather than add-on programs to the treatment of the drug user. These programs should be evidence based and open to evaluation.

In addition, there is a need for more specialist family workers in generalist services so that the needs of families can be identified and catered for more effectively.

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