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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

substance family treatment members family substance members treatment child families problem children service support work social drug youth skills alcohol systems amp

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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)