Families: forgotten in addiction treatment?

Addiction is an equal opportunity condition. Families get to suffer alongside the person with the problem. But as Alex Copello and Jim Orford noted in a past Addiction editorial, there’s a paradox here that needs attention. Firstly, evidence suggests that when families are involved by treatment services, retention in treatment is better. Retention in treatment is associated with better outcomes. It also suggests that positive outcomes are more likely for the family members. So the evidence is there, what’s the paradox? Copello and Orford are clear:

On the whole service delivery remains focused on the individual drinker or drug user, with families and other members of the user’s social network playing a very peripheral role, if any.’

Copello and Orford, 2002

They go on to say:

With very few exceptions, help for those concerned about the user is reactive, poorly thought out and marginal.

Quite damning really.

Unfortunately, there is evidence that families are also marginalised in addiction recovery research (itself the poor relative of addiction research). In their recently published paper which looks at how individuals in recovery and their families have shared and differing perspectives, Anne Dekkers and her colleagues point out more whammies for families in terms of research interest. 

According to Dekkers et al, the focus of existing research mostly attempts to capture the perspectives of individuals in recovery, with a specific focus on transitions from addiction to recovery, the role of substance use and abstinence, the role of treatment, and identity and stigma. So then is nobody interested in families?

Well, of course we are – just not enough to involve them in treatment and research it would seem.

So, what did Dekkers and colleagues find out about the different ways of looking at recovery depending on whether you were a family member or a person seeking recovery? These are explored under themes.

Consequences

There were some shared themes, but also discrepancies. As you might expect it’s the differences that are intriguing. Individuals in recovery (this included those in MAT and those abstinent) and family members both felt the pain and destruction that addiction brings, but while the individuals were focussed on negative consequences to themselves, families were aware of consequences to the individual and the wider family. They felt ‘reduced to powerless bystanders’.

Abstinence

Family members were blunt about this, mostly regarding abstinence as a prerequisite for starting recovery. Individuals in recovery were much more nuanced and saw a range of important factors of which abstinent was one. There was ambivalence amongst some of them around possible future controlled use of substances. There were mixed views on alcohol with some believing it could be safe in recovery. (See recent post on this).

Identity and behaviour

The emphasis for individuals in recovery was in relation to identity and daily life issues, growing as a person for instance, while for families it was looking for changed behaviour, with little interest in changed identity. There were striking differences in expectation of the pace of change – with family members looking for faster progress and anticipating their loved one was further on in the recovery journey than the individual actually judged they were.

Support

Both groups saw the need for this, but for individuals it sometimes felt that support was slow to grow with a rapid decline in trust from family members when relapse occurred. The existing or previous social network often included using friends who were a barrier to recovery. Those individuals whose treatment was in a therapeutic community (TC) spoke of ‘friendships for life’ founded in TC s.

Treatment

Family members felt it important that they were involved in treatment to ‘complete’ the story of the individual. They felt that without this, treatment would be superficial. (I identify – the impact of family therapy in the setting I work in is profound and often brings about profound changes for both the family and the patient). Family members had positive experiences when they were involved but also mentioned the need for long term support. In contrast, individuals only briefly mentioned family involvement in treatment as insightful.

Place in society

Individuals in recovery valued issues related to citizenship/society (in keeping with many definitions of recovery) including regaining their place, but also they saw the part that society could play in their recovery, while family members barely spoke of this. Stigma was experienced though by individuals in society, for instance when they tried to get back into work. 

This was small scale qualitative research, but it does highlight the nuance and detail that might be missed in number-crunching research. Clashes clearly occur over expectations on the pace of change, the nature of change, trust and the importance of abstinence.

Bottom line

There are multiple recommendations in the paper which are sound, but specifically on families, they say two things:

1. Families want to be involved in treatment and should be
2. Families need ongoing support in their own right, and it should be provided

Drug and alcohol deaths

My mind returns to the lack of research on families and how it might relate to substance-related deaths. I’m aware there are no easy answers to the harrowing problem of drug and alcohol-related deaths, but I do wonder if there might be an impact of some kind through having a much more assertive policy of involving family members in treatment and providing ongoing support for them. In addiction treatment we generally underplay the impact of social interventions It would be great to see research to test this out.

In Scotland, we have a national organisation – Scottish Families Affected by Alcohol and Drugs, which is a great resource. They are already trying to do both of the things above, but I wonder how receptive treatment organisations are and what priority local commissioners put on family involvement and support, even though it is embedded in our national drug and alcohol strategy. We fund our own family programme through grant funding rather than statutory funding which tells its own story.

Action

While families are devastated by addiction, family members can and do recover from it. I think that by actively pursuing family treatment involvement and ensuring robust support systems we can do better for them and consequently do better for those individuals with substance dependence. It would be great to see this prioritised in practice and research.