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Client Family-Member Participation Is Associated with Improved Residential Treatment Program Completion at an International Drug and Alcohol Treatment Center
Abstract
Prior research at Crossroads Centre Antigua has shown a 15% increase in long-term abstinence rates of clients if a family member attended the family program. This study examines the association of family program participation on client residential treatment completion. A retrospective review of records of all clients admitted from January 2004 to June 2007 was performed. Participation of client family members in the family program (a 4-day program including didactic material, workshops, group and individual counseling sessions for interested family members) was recorded. Information obtained from a limited client database, in addition to family program participation, included age, gender, country of residence, drug of choice, and 29-day treatment program completion. Data from clients having family members participate in the family program were compared with clients not having family members participate. There were 1,014 clients admitted, 681/1,014 (67%) men, mean age 41years, 733/1,014 (72%) from the United States. There were 187/1,014 (18%) clients using opioids either alone or with other drugs, 330/1,014 (33%) using cocaine or another stimulant drug alone or with other drugs, and 497/1,014 (49%) using alcohol or another non-prescribed sedative drug alone or with other drugs not including opioids or cocaine/stimulants. Of these clients, 207/1,014 (27%) had 416 family members (155/416 [37%] parents or step-parents; 133/416 [32%] spouses, significant others, or partners; 67/416 [16%] siblings or step-siblings; 38/416 [9%] children or step-children; and 23/416 [6%] other individuals) attend the family program. For all clients admitted, 902/1,014 (89%) completed the 29-day residential stay. The clients who had family members participate in the family program were significantly more likely to complete their stay (266/270 [99%]) than those clients who did not have family members participate (636/744 [86%]; chi-square p < .0005. Those with family members attending had no significant difference in other factors that may affect treatment completion, such as age (40 vs. 41 years), gender (65% vs. 68% male), country of residence (73% vs. 71% from the United States), or opioid drug (17% vs. 19%), cocaine/stimulant (34% vs. 32%) or alcohol/sedative as primary drug (49% vs. 49%). These data suggest that participation of a client family member in a family program, independent of other clinical risk factors, is associated with significantly improved treatment retention, a surrogate marker for better long-term abstinence rates following residential treatment.
... Family members who are involved in treatment and who find recovery for themselves may also benefit the recovery of their addicted loved one (Martin, Lewis, Josiah-Martin, & Sinnott, 2010;O'Farrell & Clements, 2012). Family members' participation in the intervention and treatment process can have positive effects on the addict's recovery (O'Farrell & Clements, 2012). ...
... Family members' participation in the intervention and treatment process can have positive effects on the addict's recovery (O'Farrell & Clements, 2012). Having a family member or members as part of a family program in addiction treatment has been associated with a 13% higher program completion rate for people being treated for addiction and a 15% higher rate of client abstinence at 20-month follow-up (Martin et al., 2010). ...
Addiction adversely affects families, making family recovery important. Family members appear to benefit from hope, healthy coping skills, and a readiness to change. Family recovery research is limited and relationships between these variables are underexplored. Using structural equation modeling, preparation for change at initial assessment before a family treatment program predicted higher hope and coping skills after participation. Initial levels of hope predicted coping skills posttreatment. Gender, treatment track of the addict, and family members’ relation to the addict showed significant effects. The importance of family members’ hope, coping, and readiness to change in family recovery are discussed.
... Family members who are involved in treatment and who find recovery for themselves may also benefit the recovery of their addicted loved one (Martin, Lewis, Josiah-Martin, & Sinnott, 2010;O'Farrell & Clements, 2012). Family members' participation in the intervention and treatment process can have positive effects on the addict's recovery (O'Farrell & Clements, 2012). ...
... Family members' participation in the intervention and treatment process can have positive effects on the addict's recovery (O'Farrell & Clements, 2012). Having a family member or members as part of a family program in addiction treatment has been associated with a 13% higher program completion rate for people being treated for addiction and a 15% higher rate of client abstinence at 20-month follow-up (Martin et al., 2010). ...
Craving, a compulsive motivation to use, and conscious readiness to change (RTC) are distinct motivators of human behavior. Recovery requires RTC despite involuntary cravings. A structural equation modeling analysis examining hope as a mediator between these constructs found craving to directly associate with precontemplation, while hope partially mediated the relationship between craving, contemplation, and coping. Craving's indirect effect on action toward change occurred only through hope. While craving appears to be a strong associate of precontemplation, hope appears to be an important associate of contemplation toward change and appears to be required for action. Hope also appears to be an important factor of coping in recovery.
Although research on substance use disorders (SUDs) largely focuses on the developed world, treatment programs from the developing world seldom get international attention. Focusing on India, this study was designed (1) to describe India’s treatment programs, and (2) to report Indian perspectives on critical factors related to treating SUDs. An online survey instrument was created, based on mixed-methods approach with concurrent strategies, to collect data. Participants were India’s clinicians (N = 112). Indian treatment approach suggests that SUDs must be treated by a multidisciplinary treatment team with a comprehensive plan that must include systemically focused clinical interventions in patients’/clients’ relevant relational systems. Findings may have relevance to clinicians, researchers, and policy makers globally.
Unhealthy family dynamics often develop in families where addiction is present and negatively impact individual and family health. Family members becoming ready to make personal changes might positively impact family functioning and improve family support. More research is needed to examine this relationship in family recovery. Using structural equation modeling, family member readiness to change and family functioning over time were examined. Readiness and family functioning were positively and reciprocally associated with each other across 2 assessment points. Gender was associated with initial readiness to change and family functioning. Individual readiness to change may enhance family functioning and promote recovery-oriented changes for each family member.
Dissertation: Alcohol Use Disorder and the Sibling Relationship: A Phenomenological Enquiry
The model described in this paper takes into consideration two key findings: (a) In a given year, the vast majority (90–95%) of active substance abusers do not enter treatment or self-help groups, and (b) substance abusers have frequent contact with their families (60–80% either live with a parent or are in daily contact). This paper presents a method for mobilizing and collaborating with families and extended the support system toward working with resistance and getting the substance abuser into treatment. Principles and techniques are provided for convening and structuring intervention network meetings toward that end. This intervention network approach can be used either alone or as part of an overall model, ARISE (A Relational Intervention Sequence for Engagement). The ARISE model addresses both clinical and programmatic issues in treatment engagement for substance abusers.
This study investigated the perception of family functioning of rehabilitating inner-city substance abusers and one of their family members. Subjects were 39 residents of a treatment center and 39 family members. The design was compromised experimental, comparing the group who had family members in ALANON (n = 36) with a nonrandomized control group whose family members had no help (n = 42). Data were collected three times: at the beginning of the abuser's treatment, at the end, and one month after treatment. Subjects completed two family functioning instruments: Assessment of Strategies in Families (ASF) and Family APGAR. Repeated-measure MANOVAs yielded significant differences in all family scores between the ALANON and the control groups. An increase in the perception of family effectiveness was most pronounced between time 2 and time 3, after the substance abuse program was completed. Family members changed their perceptions more than the abusers and maintained their favorable family perception, even though five of the abusers had relapsed shortly after discharge. At 3 months after treatment, the relapse rate for addicts in the ALANON group (n = 15) was 39% compared with 61% for addicts in the control group (n = 18). The difference was not of statistical significance due to the small group sizes, however. Evidence suggests the usefulness of ALANON in empowering families and assisting them in reevaluating the family system more positively.
In a randomized clinical trial, 130 concerned significant others (CSOs) were offered 1 of 3 different counseling approaches: (a) an Al-Anon facilitation therapy designed to encourage involvement in the 12-step program, (b) a Johnson Institute intervention to prepare for a confrontational family meeting, or (c) a community reinforcement and family training (CRAFT) approach teaching behavior change skills to use at home. All were manual-guided, with 12 hr of contact. Follow-up interviews continued for 12 months, with 94% completed. The CRAFT approach was more effective in engaging initially unmotivated problem drinkers in treatment (64%) as compared with the more commonly practiced Al-Anon (13%) and Johnson interventions (30%). Two previously reported aspects of the Johnson intervention were replicated: that most CSOs decide not to go through with the family confrontation (70% in this study) and that among those who do, most (75%) succeed in getting the drinker into treatment. All 3 approaches were associated with similar improvement in CSO functioning and relationship quality. Overall treatment engagement rates were higher for CSOs who were parents than for spouses. On average, treatment engagement occurred after 4 to 6 sessions.
This study examines the life circumstances and experiences of 4084 children affected by maternal addiction to alcohol or other drugs. The paper will address the characteristics of their caregivers, the multiple risk factors faced by these children, their health and development, and their school performance. Data were collected from mothers at intake into 50 publicly funded residential substance abuse treatment programs for pregnant and parenting women. Findings from this study suggest that children whose mothers abuse alcohol or other drugs confront a high level of risk and are at increased vulnerability for physical, academic, and social-emotional problems. Children affected by maternal addiction are in need of long-term supportive services.
The role of in-home work with substance use affected family members has great potential for addressing family and personal issues that are often not well addressed by continuing care interventions that involve limited contact with the family and the impact alcohol and other drug "abuse" has on the family environment. This article reviews the importance of involving the family in the recovery process and offers comparative advantages of an in-home visitation approach for assisting the substance user with maintaining substance use avoidance, reintegrating with the family, and addressing unresolved family issues affecting children and spousal relationships.
Our goal was to explore, through a Stage I NIH clinical study, the effectiveness of a manual-driven, timely response method for helping the "concerned other" get resistant substance abusers into treatment/self-help with minimum professional time/effort. A manual-driven protocol, "A Relational Sequence for Engagement (ARISE)," was applied with 110 consecutive, initial calls/contacts from concerned others; no cases excluded for research, refusal, or other reasons. The research was conducted at two upstate New York outpatient drug/alcohol clinics. Participants were concerned others who called regarding a cocaine, alcohol, or "other drug" abuser (N = 110); participating family/friends: 11 ARISE clinicians; and 110 substance abusers. ARISE is a graduated continuum starting with the least demanding option/stage, increasing effort as needed to engage substance abusers in treatment/self-help. Stage I: Coaching the concerned other to arrange a meeting of significant others, inviting the substance abuser; Stage II: 1 to 5 additional meetings (median = 2); Stage III: A modified Johnson "Intervention." Primary outcome variables were substance abuser engagement (or not) in treatment/self-help; days between first call and engagement; clinician time/effort. Predictors were concerned other, substance abuser, and clinician demographics; number of participants per case; and Collateral Addiction Severity Index. ARISE resulted in an 83% success rate (55% at Stage I). Median days to engagement was 7 (IQR = 2 to 14). Average total time (telephone, sessions) per case was 1.5 hours. Treatment/self-help chosen was 95% treatment and 5% self-help. Number of family/ friends involved correlated 0.69 with a success/efficiency index. Conclusions. A call from a family member or concerned other for help in getting a loved one into treatment is a rich opportunity for treatment professionals and agencies to engage substance abusers in treatment. These initial calls are similar to referral calls from EAPs or probation officers looking to get an individual started in treatment. ARISE provides an effective, swift, and cost-efficient option for engaging substance abusers in treatment or self-help. The more significant others involved, the greater the success of treatment engagement.
Studies have shown that individuals with substance-use problems frequently receive pressure to enter treatment. Pressure can come from institutions (e.g., criminal justice or welfare) or relationships (e.g., family or friends). Research has also shown that pressure can facilitate treatment entry. However, few studies have assessed how pressure from different sources varies.
Six hundred ninety-eight individuals entering residential or outpatient treatment for alcohol or drug problems completed face-to-face interviews soon after admission. Pressure was assessed by asking participants if others had suggested they enter treatment, including family, friends, and professionals within institutions. Additional assessments included the Addiction Severity Index and readiness to change.
Most of the participants (73%) reported some type of pressure: 29% from personal relationships, 30% from institutions, and 14% from both. The remaining 27% reported no pressure to enter treatment. Multinomial logistic regression of baseline data showed being on parole or probation, not being employed full time, and having more severe legal problems predicted pressure from institutions. In contrast, relationship pressure at baseline was predicted by severity of alcohol problems. Compared with participants receiving only relationship pressure, those receiving only institutional pressure had lower alcohol, drug, family, psychiatric, and medical severity. In addition, institutional pressure was associated with lower motivation at baseline, whereas relationship pressure was not related to motivation at all. When controlling for problem severity, baseline pressure was not associated with 12-month outcome.
Correlates of pressure from institutions for individuals to enter treatment differ from those associated with pressure from personal relationships to enter treatment. Implications of these findings for public policy, treatment, and further research are discussed.
There are significant knowledge gaps concerning the experiences of families of persons with co-occurring substance and mental disorders and the impact of families on treatment of individuals with these disorders. This paper presents a conceptual framework for examining family involvement of adults in treatment for co-occurring substance and mental disorders. An overview of the characteristics, problems, and needs of these individuals and their family members is presented. The extant literature pertaining to our conceptual framework is reviewed with focus on predictors of family involvement with clients, predictors of family member involvement in clients’ treatment, and consequences of family involvement for client treatment outcomes. Gaps in the research literature and implications for future research and practice are discussed.
The family plays a key part in both preventing and intervening with substance use and misuse, both through inducing risk, and/or encouraging and promoting protection and resilience. This review examines a number of family processes and structures that have been associated with young people commencing substance use and later misuse, and concludes that there is significant evidence for family involvement in young people's taking up, and later misusing, substances. Given this family involvement, the review explores and appraises interventions aimed at using the family to prevent substance use and misuse amongst young people. The review concludes that there is a dearth of methodologically highly sound research in this area, but the research that has been conducted does suggest strongly that the family can have a central role in preventing substance use and later misuse amongst young people.
Although motivation for drug abuse treatment is a substantial problem, unilateral intervention through concerned significant others (CSOs) represents a promising method for engaging unmotivated individuals. The Community Reinforcement and Family Training (CRAFT) program, based on principles of reinforcement, was developed for this specific purpose. In Phase I, CSOs received the CRAFT intervention, whereby they were taught skills for modifying a loved one's drug-using behavior and for enhancing treatment engagement. CSOs were evaluated at 3 and 6 months. In Phase II, engaged drug users received treatment using the Community Reinforcement Approach (CRA). A total of 62 CSOs participated in this evaluation of the effectiveness of CRAFT. CSOs completed, on average, 87% of offered treatment sessions. During the 6-month study period, 74% succeeded in engaging their resistant loved one in treatment. Reported abstinence both from illicit drugs and alcohol increased significantly for drug users engaged in treatment, but not for unengaged cases. All CSOs showed significant reductions in depression, anxiety, anger, and physical symptoms, with average scores dropping into the normal range on all measures. CRAFT provides a promising alternative to confrontational and detachment approaches in counseling CSOs to help their loved ones.
Directors of 70 (75% response rate) inpatient and 51 (54% response rate) outpatient alcoholism treatment programs run by the Department of Veterans Affairs (VA) returned questionnaires about patient and program characteristics and the extent of use of family-focused treatment modalities. Referrals to Al-Anon for spouses and to Alateen for teenage children were by far the most frequently provided services. Conjoint couples therapy was the type of direct service provided most frequently. Couples group therapy for outpatient programs and spouse education groups for inpatient programs were the next most frequently used. Family therapy was not used frequently. The majority of programs did not offer services directed at the individual needs of spouses, such as individual or group therapy and educational groups. Finally, services to children of alcoholics were nearly nonexistent being limited to referral of teenage children to Alateen. Marital and family services other than referral to Al-Anon and Alateen and conjoint couple interviews in inpatient programs were provided to fewer patients than those eligible for the services. The extent of family services offered bore little or no relationship to program characteristics (e.g., funding level, staffing pattern) but was related to patient characteristics. Programs with more middle-aged, employed, high school (or better) educated, married veterans made greater use of family-focused modalities. The results suggest the VA needs to develop policy guidelines for the type and intensity of marital and family services their programs should provide with specific determination of what responsibility, if any, VA programs have to the children living with the alcoholic veterans treated in these programs.
Many clinicians in the area of drug addiction believe that emotional problems arise from particular styles of parenting. To investigate this link, 63 young male and female addicts who had sought treatment completed the Parental Bonding Instrument which tapped their perceptions of their relationship with each parent. Addicts reported early parental experiences differing from those of a control group. Drug abusers judged their parents as cold, indifferent, controlling and intrusive. In addition, these perceptions were shared by male and female addicts. These results, together with previous research suggest that these perceptions might well point to a general risk factor for the development of a broad range of psychological and psychiatric disorders. In addition, the issue of family factors in the design and implementation of drug treatment programs needs to be addressed.
Family therapy has made a substantial contribution to the prevention of drug addiction. This approach takes fully into account psycho-social relationships in families, particularly in families experiencing addiction, as well as changes in patterns of family life and in social attitudes towards addiction. Drug addiction is a manifestation of serious dysfunctional relationships and interactions in the family and is often interrelated with child and spouse abuse. Such family situations require multidisciplinary therapy measures for which the family, with its network of relationships and behavioural interactions, rather than the individual alone, is regarded as the unit of treatment.
Adult children of alcoholics exhibit low self-esteem, excessive feelings of responsibility, difficulties reaching out, depression and the increased likelihood of alcoholism. This study examines how adult children of alcoholics discuss their experiences in an Al-Anon group and describes their perceptions of change in self, personal problems, relationships, spirituality, childhood and the Al-Anon program. Twelve sessions of one Al-Anon chapter were observed, Al-Anon members were interviewed and a coding system to assess the content of the meetings was developed. Improvements constituted 25% of reports, of which improvement in problems constituted 20%. Members reported positive changes in self. Changes in relationships with alcoholics were few, as were changes in perceptions of the program (members felt positively about the program from the start). Although spirituality constituted less than 4% of the reports, many interviewees found spirituality the last and, ultimately, one of the most valued components of Al-Anon. A common experience of parental alcoholism, and cognitive, affective and behavioral antidotes to prior socialization in an alcoholic family contributed to the program's perceived helpfulness.
A difficulty in the treatment of alcoholism is that many alcoholics referred to treatment programs never reach the referral destination, or if they do, they seldom remain involved in those programs. The present study attempted to increase participation in Alcoholics Anonymous and Al-Anon meetings. Twenty clients were selected from an outpatient mental health alcoholism treatment program and randomly assigned to either a standard referral procedure which involved giving the client information about Alcoholics Anonymous or Al-Anon; encouraging the client to attend; and providing information concerning time, date, and location of weekly meetings; or to a systematic encouragement and community access procedure which involved a phone call being made in the counseling session to a local Alcoholics Anonymous or Al-Anon member in which the member briefly talked to the client about the meeting, offered to give a ride to the client and to meet the client before the meeting and having the Alcoholics Anonymous or Al-Anon member call the client the night of the meeting to remind them of it and to encourage them to come. The results of this study showed that 100% of the experimental group attended Alcoholics Anonymous or Al-Anon within 1 week of referral and continued to attend, whereas none of the control group ever attended. The results of this study suggest that the systematic encouragement and community assess procedure are significantly more effective than standard referral systems.
Based on the 1990 US National Alcohol Survey, this note provides the first available comprehensive findings on self-reported utilization of a variety of sources of personal support and counselling for alcohol and other problems. Respondents were queried about lifetime attendance and number of times they went to identified sources of help in the prior year. Twelve-step groups included Alcoholics Anonymous, Al-Anon, Adult Children of Alcoholics, and other non-alcohol-oriented groups like Gamblers Anonymous, Narcotics Anonymous, and Overeaters Anonymous; additional questions inquired about support or therapy groups and individual counselling for non-alcohol problems. Of the US adult population, 9% have been to an AA meeting at some time, 3.6% in the prior year, only about one-third of these for problems of their own. About half these percentages, mostly women, have attended Al-Anon. Of the same population, 13.3% indicate ever attending a 12-step meeting (including non-alcohol-oriented groups), 5.3% in the last year. During the prior year a further 2.1% used other support/therapy groups and 5.5% sought individual counselling/therapy for personal problems other than alcohol. In contrast to this high reported utilization, only 4.9% (ever) and 2.3% (12-months) reported going to anyone including AA for a problem (of their own) related to drinking.
Despite the fact that unilateral therapy is often the only treatment option for women living with heavy drinkers, very few structured programs have been developed for this client group. Moreover, the programs that do exist lack empirical support (as in the case of Al-Anon) or have as their highest priority promoting change in the drinker. This article looks at unilateral therapy for women partners of heavy drinkers and concludes that although a number of promising developments have occurred in recent years, more research is needed on the benefits to the women themselves.
Parents in methadone treatment were offered an experimental intervention, Focus on Families, designed to reduce their risk of relapse and their children's risk of substance use. Experimentally assigned volunteers participated in systematic group training in relapse prevention and parenting skills, and received home-based case management services. Immediate posttreatment outcome results reported here include analyses of covariance controlling for baseline measures. Analyses show experimental parents held more family meetings to discuss family fun, displayed stronger refusal/relapse coping skills, demonstrated stronger sense of self-efficacy in role-play situations, and had lower levels of opiate use than control subjects. No significant differences in family bonding, family conflict, or other measures of drug use were found. The utility of intervening with drug-addicted parents in methadone treatment is discussed in light of these findings.
Children whose parents abuse drugs are exposed to numerous factors that increase the likelihood of future drug abuse. Despite this heightened risk, few experimental tests of prevention programs with this population have been reported. This article examines whether intensive family-focused interventions with methadone treated parents can reduce parents' drug use and prevent children's initiation of drug use.
Parents were assigned randomly into intervention and control conditions and assessed at baseline, post-test, and 6 and 12 months following the intervention. Children were assessed at baseline, and 6- and 12-month follow-up points.
Two methadone clinics in Seattle, Washington.
One hundred and forty-four methadone-treated parents, and their children (n = 178) ranging in age from 3 to 14 years old.
The experimental intervention supplemented methadone treatment with 33 sessions of family training combined with 9 months of home-based case management. Families in the control condition received no supplemental services.
Parent measures included: relapse and problem-solving skills, self-report measures of family management practices, deviant peer networks, domestic conflict and drug use. Child measures included self-report measures of rules, family attachment, parental involvement, school attachment and misbehavior, negative peers, substance use and delinquency.
One year after the family skills training, results indicate significant positive changes among parents, especially in the areas of parent skills, parent drug use, deviant peers and family management. Few changes were noted in children's behavior or attitudes.
Programs such as this may be an important adjunct to treatment programs, helping to strengthen family bonding and to reduce parents' drug use.
Residential treatment programs specifically designed for alcohol/drug-addicted women and their children have become a popular treatment modality across the United States. Outcome evaluation of these programs are beginning to show promising results. In this article, outcome data from a study of a residential substance abuse treatment program for women and young children in rural South Carolina will be presented. Data from 35 women and 23 children in the area of addiction severity, parenting and child emotional and behavioral development at 6 and 12 months following discharge from a substance abuse residential treatment program is examined. Results showed that women who completed treatment had better scores on addiction severity and parental stress, and their children had improved behavioral and emotional functioning at 6 and 12 months after discharge from the program. These results suggest that residential treatment has benefits for mothers and their children. This data adds to the growing body of evidence supporting intensive and inclusive care for certain groups of individuals with substance use disorders during critical periods.
The model described in this paper takes into consideration two key findings: (a) In a given year, the vast majority (90-95%) of active substance abusers do not enter treatment or self-help groups, and (b) substance abusers have frequent contact with their families (60-80% either live with a parent or are in daily contact). This paper presents a method for mobilizing and collaborating with families and extended the support system toward working with resistance and getting the substance abuser into treatment. Principles and techniques are provided for convening and structuring intervention network meetings toward that end. This intervention network approach can be used either alone or as part of an overall model, ARISE (A Relational Intervention Sequence for Engagement). The ARISE model addresses both clinical and programmatic issues in treatment engagement for substance abusers.
We reviewed 36 randomized studies of family-involved treatment and comparison conditions. A meta-analysis showed a medium effect size favoring family-involved treatments, over individual treatment or wait-list, for outcomes of alcohol use, treatment entry/attendance, and family adjustment. Studies of family-involved treatment when the alcoholic is unwilling to seek help show: (1) Al-Anon facilitation and referral help family members cope better; (2) the popular Johnson intervention apparently does not effectively promote treatment entry; and (3) Community Reinforcement and Family Training promotes treatment entry and should be disseminated if replicated. Studies of family-involved treatment to aid recovery when the alcoholic has sought help show: (1) evidence supporting behavioral couples therapy (BCT) has grown considerably; (2) the disulfiram contract procedure should be disseminated as part of a BCT treatment package; and (3) studies of family systems and of family disease approaches are beginning to appear in the literature. Future studies need to include more women and minority patients and focus on children.
This article examines a comprehensive, residential substance abuse treatment program for women and their children. A majority of the 72 participants studied were African American single mothers, for whom crack/cocaine was the drug of choice. The women and their children were assessed repeatedly during treatment, and at 3, 6, and 12 months postdischarge. Program impact was estimated by comparing the outcomes of three groups that differed in the amount of treatment they received: early dropouts, late dropouts, and treatment graduates. Program graduates showed more positive outcomes than the nongraduate comparison groups in the areas of drug use and negative consequences of use, employment and self-sufficiency, and family interaction skills. Young children enrolled in treatment with their mothers were assessed using a developmental screening test, and older children with a measure of drug refusal skills. Results from both child measures suggest substantial improvement.
The first 50 Caribbean clients admitted to a private, multicultural, not for profit addiction treatment center in Antigua, West Indies, were compared with the first 100 non-Caribbean clients admitted. There was no significant difference in age, 38 years (18-61 years) versus 40 years (22-63 years), or gender, 74% versus 67% male. Caribbean clients were more likely to be Black, 68% versus 2%, P < .001. Caribbean clients were less likely to have a prior psychiatric diagnosis, 18% versus 43%, P < .01, or to have been in prior treatment program, 22% versus 64%, P < .001. Caribbean and non-Caribbean clients were equally likely to be polydrug users, 48% versus 50%, and to use alcohol as a primary drug, 52% versus 51%. Caribbean clients were more likely to use cocaine, 30% versus 11%, P < .01, and marijuana, 12% versus 0%, P < .001, but less likely to use heroin, 6% versus 30%, P < .001 or pills, 0% versus 8%, P < .05. Caribbean clients were less likely to have elevated MCV, 24% versus 57%, P < .001 or serum transaminases, 23% versus 46%, P < .01. Differences between groups in this multicultural setting warrant further investigation.
Until recently, few programs were available for children whose mothers are in recovery. A refinement of the gender-specific model of substance abuse treatment, the "family-focused" approach, has placed increased emphasis on the needs of children and other family members. However, because these programs are relatively new, little is known about the effectiveness of this type of treatment for either the mother or her children. This article presents findings from a three-year evaluation of a family-focused residential treatment program for women and their children. Longitudinal assessment of the mothers indicated that their psychosocial status and parenting attitudes improved over time. Additionally, the mothers remained in treatment longer. At intake, as a group, the children who were birth to three years of age did not exhibit developmental delay. However, developmental concerns were identified for some children in the areas of motor and/or language development. The results reported here provide beginning evidence that family-focused treatment improves retention, psychosocial functioning, and parenting attitudes of pregnant and parenting women. It also provides a mechanism for early identification and intervention for children.
To review the literature on the impact of parental problem drug use on children, and indicate the efficacy of key evaluated interventions to reduce the impact of parental drug use on children.
Comprehensive narrative review of English language published research and intervention spanning the last three decades identified through searching library databases and citation.
Problem drug use can impede parenting and the provision of a nurturing environment. Although small-scale, localized and resource-intensive these key evaluated interventions show cautious optimism that problem drug-using parents can reduce drug use and achieve better family management. Children have rarely been directly the focus of intervention.
Wider application and more rigorous evaluation of interventions in this area are needed. Given the scale of the problem it is important to establish how statutory services can apply the lessons of these more localized interventions.
This review examines the results from 19 outcome studies, involving 1,501 cases, within 10 different clinical approaches to getting alcohol or drug abusers to engage in treatment or self-help. Each approach is summarized and its "success rate(s)" presented. Comparisons are made across various subcategories, such as alcohol vs. drug abusers, adolescents vs. adults, and experimental conditions vs. controls. A distinction is drawn between "Dual-Purpose" approaches, which combine engagement with counseling of the concerned person who originally sought help for the substance abuser, and "Engagement-Primary" approaches, which generally confine their efforts (through working with family members and others) to getting the substance abuser into treatment/self-help. "Best bet" clinical options are presented in terms of which particular approach appears to have the edge with which kind of substance abuser.
Twelve families responded to posters displayed in a methadone clinic for inclusion in a pilot study assessing the viability and potential utility of an intensive, multi-component family-focused intervention, the Parents Under Pressure programme. The programme was designed to improve child behaviour, decrease parental stress and improve family functioning in methadone-maintained families by targeting affect regulation, mood, views of self as a parent, drug use and parenting skills. Nine of the families completed the programme delivered in their homes; eight were recontacted at 3 months. Each family reported significant improvements in three domains: parental functioning, parent-child relationship and parental substance use and risk behaviour. In addition to the changes in family functioning, the majority of families reported a decrease in concurrent alcohol use, HIV risk-taking behaviour and maintenance dose of methadone. The families reported high levels of satisfaction with the programme. It is recommended that future studies include independent measures (e.g. behavioural observations) of child outcome and parental functioning. The results were optimistic and provided the impetus to evaluate the treatment programme using a randomized controlled trial.
Women (N=171), distressed from their partners' untreated alcoholism, received either coping skills training (CST), 12-step facilitation (TSF), or delayed treatment (DTC). CST and TSF resulted in lower depression levels than DTC but did not differ from one another. Skill acquisition mediated the treatment effects of CST; Al-Anon attendance did not mediate the TSF effect. Lower depression levels were maintained at 12 months with no differences between groups. Partner drinking decreased from pretreatment to follow-up in the CST and TSF conditions. However, for partners with a history of relationship violence, drinking improved across follow-up in the CST condition but worsened in the TSF condition. Partner relationship violence was less in the CST condition. CST may be particularly useful for women experiencing physical violence from a partner with alcoholism.
The outcome of a 29-day residential addiction treatment programme for persons from Antigua and Barbuda with addiction to drugs or alcohol was assessed. All 100 patients entering the drug and alcohol treatment programme at Crossroads Centre Antigua between November 1998 and October 2002 were included. All patients were assessed with regards to drug or alcohol use or abstinence in November 2002 using telephone and mail follow-up as well as informal follow-up with families and other community contacts. Crossroads Centre Antigua is a 35 bed, 29-day residential treatment centre for drug and alcohol addiction serving patients from developed countries (85%) and from the Caribbean region (15%). Patients records were also reviewed to obtain age, gender, ethnicity, drug of choice, years of problematic use, completion of the 29 day programme, family member participation at Crossroads Centre Antigua (a four-day programme) and acceptance of halfway house placement. Of the 100 Antiguan patients admitted, 46 (46%) were abstinent (non-relapsers) at average 20.7+/-14.7 months after treatment. Abstinence did not have to be continuous. Forty-nine were known to be using drug or alcohol (49%) and five (5%) were lost to follow-up and considered to be using drugs (relapsers). Age (37.5 vs 41.1 years), gender (28% vs 22% female), ethnicity (87% vs 87% Afro-Caribbean), years of harmful use (12.7 vs 12.5 years) did not differ significantly between relapsers and non-relapsers. Crack cocaine use (67% vs 65%) and alcohol use (26% vs 31%) as primary addiction did not differ significantly between relapsers and non-relapsers. Relapsers were significantly less likely to complete the 29- day programme (81% vs 100%, p < 0.01), have family members participate at Crossroads (32% vs 54%, p < 0.05) or accept halfway house placement (4% vs 54%, p < 0.001). In conclusion, abstinence was achieved in 46% of those entering treatment, in 51% completing treatment, in 60% whose families participated and in 92% of those accepting halfway house placement.
Alcohol and drug problems affect not only those using these substances but also family members of the substance user. In this review evidence of the negative impacts substance misuse may have upon families are examined, following which family-focused interventions are reviewed. 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. The evidence base for each of the three types is reviewed. Despite methodological weaknesses in this area, a number of conclusions can be advanced that support wider use of family focused interventions in routine practice. Future research needs to focus on (1) pragmatic trials that are more representative of routine clinical settings; (2) cost-effectiveness analyses, in terms of treatment costs and the impact of interventions on costs to society; (3) explore treatment process; and (4) make use of qualitative methods. In addition, there is a need to define more clearly the conceptual underpinnings of the family intervention under study.
To describe a set of standard questionnaire measures for the assessment of the needs of family members of relatives with alcohol, drug or gambling problems, and to present evidence of their reliability and validity from a series of related studies.
Includes cross-sectional and repeated-measurement studies.
Family members affected by and concerned about the problem drinking or drug-taking of close relatives in treatment and non-treatment samples in the United Kingdom (white and Sikh) and Mexico City; family members of untreated heavy drinkers; and family members of problem gamblers.
Four measures derived from a stress-strain-coping-support model of alcohol, drugs and gambling problems and the family: Family Member Impact scale (FMI), Symptom Rating Test (SRT), Coping Questionnaire (CQ), and Hopefulness-Hopelessness scale (HOPE). FMI, SRT and CQ assess stress, strain and coping, respectively. The exact role of HOPE in the model remains to be determined. The support component remains unmeasured.
Results from a number of studies support the internal reliability, discriminant and construct validity and sensitivity to change of the SRT and its two constituent scales (psychological and physical symptoms) and at least two subscales of the CQ (engaged and tolerant-inactive coping). Although showing evidence of satisfactory reliability and some evidence of discriminant validity, further work may be required on the CQ withdrawal coping subscale. Evidence suggests that the FMI is reliable and valid and may have a factor structure that will support future research (distinguishing worrying behaviour from active disturbance). HOPE is a new measure showing promising characteristics.
A set of standard measures is available for helping to assess the needs of concerned and affected family members, derived from an explicit model of the family in relation to excessive drinking, drug taking or gambling. It may have a role to play in correcting the current neglect of the needs of such family members, estimated to be in the region of nearly a million adults in Britain alone.
Recent developments in research and practice have highlighted the effectiveness of family interventions in substance misuse treatment. The present paper will critically review studies of family approaches published over the past 12 months, assess the current state of this field and suggest future directions.
Family interventions lead to positive outcomes for both misusers and family members. Some recent interventions have widened the focus also to include other members of the user's social networks and have focused on a range of treatment goals.
An increasingly robust evidence base supports family-focused and social network-focused interventions in substance misuse treatment. Recent studies have continued to show that family and network approaches either match or improve outcomes when compared with individual interventions. Research needs (and is starting) to consider a broader set of outcomes relevant to family and network interventions, besides simply making an impact on substance use. The major challenge involves implementation of family approaches in routine service provision; interventions with most evidence supporting them are not used routinely in practice. Research studies and policy initiatives need to focus on dissemination of family approaches and their integration into treatment services.
Through the use of published literature and empirical research, the authors explore the differing conceptual frameworks, techniques, and effectiveness of various family interventions for change-resistant, substance-abusing adults. The 2 dominant programs in place to help families and friends deal with the addiction of an adult loved one are the Johnson Intervention and Al-Anon. Research on these 2 programs is presented, followed by an outline of promising alternative approaches. These include A Relational Intervention Sequence for Engagement, Community Reinforcement Training, Community Reinforcement and Family Training, Unilateral Family Therapy, and Pressures to Change. The effectiveness and appropriateness of these approaches in different situations are discussed. In addition, areas in need of further study are pointed out.
Because "substance abuse" is a "family disease" of lifestyle, including both genetic and family environmental causes, effective family strengthening prevention programs should be included in all comprehensive substance abuse prevention activities. This article presents reviews of causal models of substance use and evidence-based practices. National searches by the authors suggest that there is sufficient research evidence to support broad dissemination of five highly effective family strengthening approaches (e.g., behavioral parent training, family skills training, in-home family support, brief family therapy, and family education). Additionally, family approaches have average effect sizes two to nine time larger than child-only prevention approaches. Comprehensive prevention programs combining both approaches produced much larger effect sizes. The Strengthening Families Program (SFP) is the only one of these programs that has been replicated with positive results by independent researchers with different cultural groups and with different ages of children. Few research-based programs have been adopted by practitioners, partly because of technology transfer issues. Overall, research on ways to improve dissemination, marketing, training, and funding is needed to improve adoption of effective prevention programs.
Effective parenting is the most powerful way to reduce adolescent problem behaviors. Dissemination of research-based family interventions has been slow, with most practitioners still implementing ineffective programs. This article reviews 2 federal studies that involved national searches for effective family interventions targeting pre-birth to adolescence: Preventing Substance Abuse Among Children and Adolescents: Family-Centered Approaches (Center for Substance Abuse Prevention, 1998) and Strengthening America's Families (R. Alvarado, K. L. Kumpfer, K. Kendall, S. Beesley, & C. Lee-Cavaness, 2000). Results identified 3 effective prevention approaches, 13 principles of effectiveness, and 35 programs. Recommendations include increased dissemination research on training and technical assistance systems, adoption with fidelity and quality, and gender-, age-, and culturally sensitive adaptations.
No more letting go: The spirituality of taking action against alcoholism and drug addiction
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A comparison of Caribbean clients failing to complete and those who did complete a 29-day residential drug treatment program in Antigua
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More research to establish the " best practice " for family interventions and family treatment is needed
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Comparison of clients not completing a 29-day stay and those completing stay at a residential drug treatment center in Antigua
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In-home family support has been proposed recently for drug use-affected fam-ilies (Gruber & Fleetwood
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