the Debate David McPhillips Deputy Manager CSMT Msc Drug amp Alcohol Policy Trinity 2012 Current PhD student UL Psychology Department Focusing on EBT and retention of youth substance misusers ID: 550003
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Slide1
Broadening the Debate
David McPhillips
Deputy Manager CSMT
Msc
Drug & Alcohol Policy Trinity 2012
Current PhD student- UL Psychology Department-. Focusing on EBT and retention of youth substance
misusersSlide2
Topics
Rationale for supporting families
Type of support
Experience of CSMT
Populist views- alcoholic family
Treatment outcomesSlide3
Introduction
Both generic and specialist health and social services have long recognised the difficulties experienced by family members of problem drinkers and drug users, but the provision of helping services for such family members has rarely been as systematic as it might be.
Furthermore, some of the better-known models of service provision in this field have been based on controversial family systems ideas which assume that all family members are themselves dysfunctional or ‘
codependent
‘ and as such in need of treatment- ‘detach with love’ (Butler 2012)
New models of work in contrast to previous held beliefs including:
‘5-Step Method: stress, strain, coping responses.
CRAFT – family member influences substance
misuser
to seek treatment.Slide4
The attempt to make a bridge between two systems:System one – substance treatment systems – primarily focussed on individual adult patient health outcomes
System two – child care systems – primarily focussed on parent/child dyad and social/health outcomes for children
Denial of mutual impact of systems
Lack of cohesive response
Hidden Harm (ACMD, 2003)– what actually was it?Slide5
Rationale for working with family members
Alcohol and drug problems affect not only those using these substances but also family members of the substance user.
There is a solid evidence base for the negative effects of
substance misuse in the family: especially with spouses
and parents (
Copello
et al 2005).
Very large number of
studies demonstrate negative effects on children while they are still young and in early adolescence (
Velleman
2007).
Substance misuse can impact
negatively on a range of family systems and processes including: family rituals, roles within the family, family
routines, communication.
.Slide6
Continued
Problems such as domestic and other types of violence, child abuse, individuals driving while intoxicated or disappearing for days on end are all typical types of behaviour that people have described as stressful and with which they have to cope
Substance
misuser’s
often report that family members prompted treatment seeking
Family members can influence substance
misuser’s
behaviourSlide7
Interventions
Several family-focused interventions have been developed. They can be broadly grouped into three types:
(1) working with family members to promote the entry and engagement of substance
misusers
into treatment;
(2) joint involvement of family members and substance misusing relatives in the treatment of the latter; and
(3)interventions responding to the needs of the family members in their own right. Slide8
Working with family members to promote
the engagement of substance
misusers
into treatment
CRAFT an extension of the Community Reinforcement Approach (CRA) method that aims to work with ‘concerned significant others’ (CSOs) to reinforce non-substance misusing behaviour through a positive reinforcement
process.
Family member can influence behavioural change in user
Substance
misusers
often report that family pressure impacted on decision to seek treatment (
Prochaska
& Di Clemente)
Family members can be very knowledgeable about the
misuser
and this information can be used to withdraw ‘rewards’ and influence behavioural change
Removes
pathologising
of families (Alcoholic family-some way damaged)
EmpowersSlide9
Goals of CRAFT
Reduce loved one’s substance misuse
Engage loved one into treatment
Improve the functioning of the concerned person- emotional, physical, relationships Slide10
5 Step Method- Helping children and family members
An important
principle
of
the model is that
living with
a highly stressful
experience such
as the impact of an addiction problem in the family,
may lead
to psychological and physical symptoms of ill health in
family members
other than the substance user (
Copello
2010
)
In addition
to
the methods outlined earlier, this approach may
benefit children
by reducing the levels of stress they experience, and
the provision
of relevant information may help the child to
understand concepts
(such as ’tolerance,’ ’blackouts’ and ’withdrawal
’) and
the parent’s behaviour, helping to reduce self-blame and
guilt about
parental drinking (
Emshoff
1999Slide11
The 5-Steps
Getting to know the family member and the problem – exploring stresses and strains
Providing relevant information
Exploring and discussing coping behaviors (research indicates 3 broad types of coping – Engaged, Tolerant and Withdrawal)
Exploring and enhancing social support (useful to draw a social network diagram)
Ending & exploring additional needs and further sources of helpSlide12
Community Substance Misuse Team- www.csmt.ie
Early intervention service
Cover the Mid-West- Clare, Limerick City & County, North Tipperary
Multi-disciplinary team- Staff have background in social work, counselling, youth work, drug and alcohol policy, addiction studies.
Seeks to provide an accessible, non judgmental service to parents and adolescents in the Mid-West region
Tier 2- Education/Prevention service
initially
Demand has steered service into Tier 3 with a treatment focusSlide13
CSMT
High number of referrals from ‘problematic’ youth substance misusers- social work, probation, family member, youth-services.
Generally high levels of engagement from youths > 10 sessions and majority of guardians engage in the process- consent must be obtained to utilise service for U18’s
Urban
v’s
rural – engagement levels, presenting issues vary, displacement into rural areas, isolation, tradition of service attendance
v’s
shame, guilt, lack of trustSlide14
CSMT
Utilises the Adolescent Community Reinforcement Approach for youth substance misusers – EBT
ALL staff are accredited and one in house ACRA Trainer
ACRA consists of 14 sessions, CBT elements- FA, Happiness scales, skills element- problem solving, communication, job counselling and also a family element 2-3 sessions focusing on:
Relationship happiness scale – care giver and young person
Communication
Problem solving
Developing empathy and support
Reducing conflict in the home
Clear boundaries
Improving parental capacity Slide15
One to one work and group sessionsPhone and text support
Crisis support
Space to decide on approach to deal with youth- intimidation, drug debts, cohesive response
P
arenting support groups.
How?
ACRA tools
CRAFT
5 Step Method
Relaxation groups
Alternative therapies
Being available as a worker!
No judgement- approx. 80% of 15-16 year olds will consume alcohol,
approx
20% of 15-16 year old an
illict
drug- ESPAD study,
Normalisation of licit and illicit substance misuse
Services provided to familiesSlide16
CSMT- SFP
Responsible for delivery of Strengthening Families Programmes in collaboration with the local FRC’s
SFP- 14 week skill based EBP
Strengthening families has been proving a successful means of providing support and tools / skills to families in the Mid-West region over the past 5 years. In other areas research has shown the potential benefits of the programme in increasing the strengths of family relationships, parenting skills and youth social and life skills: Slide17
SFP Overview
Typical night:
30 minutes: Dinner families + facilitators
1st Hour:
Separate
Teen Group & Parent Group
2
nd
Hour: Families re-join & work in small groups
Home exercises for teens, parents, family
Debriefing session for facilitators.
Key objectives of SFP:
To provide family skills training programme to reduce problem behaviours in young people.
Improve parenting skills to ensure better positive role model behaviour from parents.
Put training and support structure in place for vulnerable families.
To reduce risk factors for families.
Build resilience and support families to reduce risk factors.
To provide an outlet for families in the community experiencing stress and disadvantage to build parenting, social & communication skills.
Slide18
CSMT
Clare Youth Group- a support group for youths impacted by
parental
substance
misuse: Interagency approach with HSE,
Bushypark
, MWRDAF, Clare
Youthservice
Positive outcomes
for participants- ‘a space to difficulties at home’
Facilitators have youth work and counselling background
Programme focuses on improving coping skills in a group format
Hard to reach
cohort makes it difficult to engage youths
Support provided post groupSlide19
What has CSMT learned as of December 2014
Engagement of youths is needed and ‘wanted’
‘FEAR’ is driving ineffective responses
Treatment needs to focus on improving protective factors in young people and building the capacity of families to respond effectively
Family members are often the ‘most impacted’ in terms of health and wellbeing (5 step questionnaire) and as such need to be supported
‘Relationship matters’- both with youths and parents
Communication & Trust enable successful outcomes
Generally referrals for youths impacted come from their parent(s) who are in recovery and reflecting on their behaviour
Targeting those affected by a family member’s substance misuse is challenging and time consuming
Youths respond to ‘interest’
Make a service accessible: local clinics in the areas – build on relationships already in place
Slide20
Urban v’s Rural CSMT
Service trust
Stigma
Guilt and shame
Service engagement
Lack of tradition of services in areas
Different presenting issues
Different thresholds from social workers and other professionals who refer in?
Alternative activities
Isolation
Protective factors
AvailabilitySlide21
Family as a protective factor:
Y
oung single mother, 26
Son 2 years old when heroin addiction began- active addiction for 4 years- then long term treatment in a mother and child treatment facility- Ashleigh house-
Coolmine
.
No social work involvement. Grandparents highly supportive as were other family members.
Child now 11- no knowledge or understanding that their were problems in the past, the impact had been greatly minimised due to? Question: Is this possible - Discuss
“The
most positive thing is that my son didn’t have to grow up and be exposed to all that shit. That I had my life back that I had initially and more, that I have my confidence back, do more things, go to college, getting to know yourself as a person and improving
myself
(Gina)” David
McPhillips
’ ‘Recovery from illicit substance misuse’ 2012Slide22
Continued
Child now 11- impact of addiction had been greatly minimised due to?
Role of grandparents in maintaining rituals
Emotional support maintained
No conflict in front of child
No discussion around ‘addiction’ in front of child
Child not engaged in the process or used in a manipulative way to alter behaviour
Consistency for the child
Language used- treatment was a ‘job’
Protective factors in place
Lack of conflict in the home, child was not exposed to conflict
Treatment model exposed to, the concept of ‘de-addiction’- ‘not being sick for life’ Slide23
Case: CSMT
Grandmother presented
at the service concerned about her daughters
benzo
use. 2 grandchildren in the home, 14 and 10. all living in small home as well as partner of grandmother. Grandmother was engaged in trying to prevent her daughter from using drugs. Grandmother would check the bags of her daughter with her grandson (10) trying to find evidence of drug use. Grandmother and daughter had numerous conflicts in front of the children, grandmother’s partner also lived in the house and was a positive role model for the children.
Grandson 14 engaged with the service- very angry, felt ‘embarrassed’ , confronted mother a number of times, used name calling to elicit change in his mother, very abusive towards his mother
Daughter engaged with the service- would not acknowledge drug problem or affect on family
Grandmother willing to engage in the service
What are the supports this family could benefit from?Slide24
The ‘Alcoholic Family’
Popular cultural approach to this issue based on American ideas about addiction and recovery
Alcoholism is described a family disease, which means that every member of the family is symptomatic or dysfunctional, and that all family communications and relationship systems are unhealthy
The implication is that children of problem drinkers are inevitably damaged – emotionally and behaviorally – both in their childhood and perhaps in the long-term
Such families are thought to need specialist ongoing counselling (Butler)Slide25
Dysfunctional Roles in ‘Alcoholic’ Families
Alcoholic –stereotypically husband / father
Enabler / Codependent – usually wife/mother who is emotionally martyred and super-responsible
Hero – often oldest child who is an overachiever with low self-esteem
Scapegoat – delinquent, provocative child who incurs the wrath of school systems and juvenile justice systems
Lost child – a child who remains unobtrusive and is ‘no trouble’
Mascot - a child who uses
humour
compulsively to deal with anxiety
(Butler)Slide26
Critique of ‘Alcoholic Family’ Concept
This concept reflects a negative stereotypical view, lacking empirical evidence to support it, and ignoring protective ‘mediators’ and individual resilience
Parental drinking problems are, however, an important risk factor for the creation of children’s problems
Outcomes vary enormously and problems are not unique to this type of dysfunctional family
More specific stressors: 1) marital conflict between parents;2) inconsistent parenting & rule setting; 3) breakdown of ‘family rituals’
Professionals should assess families carefully, rather than assuming that they are ‘alcoholic families’ Slide27
Resilence
Despite the evidence of increased risks to children
living with problem drinkers
, a large body of evidence suggests that most are
remarkably well-adjusted
(
Sher
1991) or resilient (
Velleman
1999
)
Resilience has been variously defined as “an interactive
concept that
is concerned with the combination of serious risk
experiences
and a relatively positive psychological outcome despite those experiences
”
(
Rutter 2006)Slide28
Resilence
Velleman
2007
identified a range of factors that provide evidence of
resilience in
children of substance misusers, including:
deliberate planning by
the child that their adult life will be different
;
high self-esteem and
confidence;
self-efficacy
;
an
ability to deal with change;
skills and
values that lead to good use of personal ability;
a
good
range of
problem-solving skills;
feeling
that there are choices;
feeling in control
of their own life; and previous experience of success
and achievement
. Slide29
Importance of Family Rituals
Concept reflecting how children thrive on security, stability and predictability as a feature of their lives
Depending on how the non-drinking parent copes, the fabric of family life can be largely preserved against the depredations of the other parent’s alcohol problem
The rituals in question are: 1) daily (e.g. mealtimes, bath & bedtime games, school,
creche
etc.; 2) annual (
e.g
birthdays, Christmas, summer holidays); 3) lifetime (e.g. First Communion, Confirmation, family weddings)
Where rituals are preserved risk is reduced – regardless of severity of parental alcohol dependenceSlide30
CSO- Concerned significant other
Research
suggests that having a supportive adult
or confidant
, either within the immediate family (if only
one parent has
a drink problem) or in the extended family and beyond,
can help
to build resilience, encouraging the development
of functional coping
behaviours.
The
social support provided by
these significant
adults (
e.g. relatives
, teachers) can help to alleviate
the risk
of developing maladaptive coping strategies (such as drug
and alcohol
use) and the onset of emotional or mental health
problems.Slide31
Summary
Family members play a vital role in substance
misuser’s
accessing treatment
Family members can be heavily effected by a substance misuse
Supporting family members improves overall treatment outcomes
Children living with parents with alcohol problems are at risk rather than inevitably doomed
Professionals should assess carefully for moderators as well as stressors
Family ritual preservation and a reduction in marital disharmony are protective for children, and non-drinking parents can be helped to improve their coping strategies (e.g. through use of Stress-Strain-Coping-Support , 5-Step model)Slide32
Policy Implications
Families are demonstrably important in this area, yet little emphasis is given to them.
Family involvement in interventions, either as part of successful treatments for problem
misusers
or as needing help in their own right needs to be facilitated by services
There are major issues of child protection raised by the large numbers who reside with substance misusing parents
Child protection issues with youth substance
misusers
?
Does treatment work? The traditional residential treatment systems are evidenced to have minimal long term impact yet popular beliefs tells us ‘they need treatment’
Youths do want to engage in services- current PhD study on youth retention and engagementSlide33
Reading List
Wegscheider
-Cruse, S. (1989).
Another Chance: Hope and Health for the Alcoholic Family.
(Palo Alto, California: Science and Behaviour Books).
Geringer
Woititz
, J. (1990).
Adult Children of Alcoholics
(revised edition). (Deerfield
Beach,Florida
: Health Communications Inc.).
Anderson, S. (1994). ‘A Critical Analysis of the Concept of
Codepency
’,
Social Work,
39, 677-685.
Wolin
, S.J. and
Wolin,S
. (1994).
The Resilient Self: how survivors of troubled families rise above adversity.
(New York: Villard Books).
Velleman
, R. and Orford, J. (1999).
Risk and Resilience: Adults Who Were the Children of Problem Drinkers.
(Reading: Harwood).
Velleman
, R.,
Copello
, A. and Maslin, J. (
eds
) (1998).
Living with Drink: women who live with problem drinkers.
(London: Longman).
Orford
, J.,
Natera
, G.,
Copello
, A. et al. (2005).
Coping With Alcohol and Drug Problems: The experiences of family members in three contrasting cultures
. (London: Routledge).
The 5-Step Method: A Research-Based Programme of Work to Help Family Members Affected by a Relative’s Alcohol or Drug Misuse.
(
Drugs: education, prevention and policy, vol. 17, supplement 1, 2010)