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In this article we describe our work in trying to influence whole service teams to move their practice towards greater involvement of affected family members. Work with five teams is described. The process varied but in all cases it included recruitment of the team, training, continued support and evaluation of results. Use of a standard questionnaire for assessing attitudes towards working with affected family members showed significant changes in team members' knowledge, confidence and team support for working with family members. Records of all project events and meetings suggested that change takes time but that a "cultural change" can take place whereby earlier misgivings are dispelled and positive attitudes towards involving family members become embedded in a team's approach. Diary audit indicated that the frequency of involvement of family members in sessions can be increased three- to five-fold, with teams beginning to carry out work with a diversity of family members, in diverse ways and with diverse positive outcomes. In a number of cases, teams were encouraged to institute new family-friendly procedures, for example changes to appointment letters, assessments and design of waiting and counselling rooms. Lessons have been learnt, including the need to accommodate different levels of initial experience of working with family members, and the need to be clear about project aims and objectives. Sustainability of change remains an issue. A general conclusion is that the capacity of services to take on work with family members affected by substance misuse of close relatives varies greatly. Where organizations already have a mission to involve family members, capacity is good. Where alcohol and drug services have previously been focused on individuals who are misusing substances, change is difficult but can be achieved. For most non substance-specialist organizations, such as primary care health centres and most non-statutory organizations, capacity is very limited. In addition to training and continued support for practitioners, explicit commissioning of work with family members combined with management support is necessary. (Contains 5 tables and 1 figure.)

This article outlines the stress-strain-coping-support (SSCS) model which underpins the whole programme of work described in this supplement. The need for such a model is explained: previous models of substance misuse and the family have attributed dysfunction or deficiency to families or family members. In contrast, the SSCS model assumes that having a close relative with a substance misuse problem constitutes a form of stressful life circumstances, often longstanding, which puts affected family members at risk of experiencing strain in the form of physical and/or psychological ill-health. Coping and social support are the two other central building blocks of the model. Affected family members are viewed as ordinary people faced with the task of coping with such stressful life circumstances. It is an assumption of the model that, difficult though the coping task is, family members need not be powerless in maintaining their own health and helping their relatives. Good quality social support, in the form of emotional support, good information and material help, is an invaluable resource for affected family members, supporting their coping efforts and contributing positively to their health. The 5-Step Method, to be described later in the supplement, is based on the SSCS model. It can be seen as a way of increasing the positive social support available from professional sources. (Contains 1 table and 1 figure.)

The article begins by making the point that a good assessment of the needs and circumstances of family members is important if previous neglect of affected family members is to be reversed. The methods we have used in research studies are then described. They include a lengthy semi-structured interview covering seven topic areas and standard questionnaires for assessing the impact of substance misuse on the family member and whole family, and the family member's symptoms of psychological and physical ill health and ways of coping. Also described are two methods for assessing social support (SS) available to a family member: drawing a SS network diagram; and a recently developed family member social support scale. The remainder of the article discusses the challenge of introducing standard family assessment and outcome monitoring into routine service practice, including the need for shorter versions of those assessments that have been used in research. (Contains 4 tables.)

Background: The Coping Questionnaire measures affected family members' responses to their relatives' substance misuse related problems. The Coping Questionnaire examines three main coping strategies: engaged, tolerant-inactive, and withdrawal coping. Objectives: The aim of the current study was to compare competing conceptual measurement models across two countries, including one-factor, three-factor, and higher order factor models. Methods: Secondary analysis of data from five previous studies was conducted. Samples of affected family members from England (N = 323) and Italy (N = 165) were aggregated into two country specific groups. Series of confirmatory factor analyses were performed to test the degree of model fit and the effects of socio-demographic variables on the coping factors. Results: A bifactor model fitted the data most closely relative to the one- and three-factor models. High rates of common variance (60–65%) were attributable to the general coping factor, while a high proportion of the variance related to the withdrawal coping subscale score was independent (66–89%) of the general coping factor. Family members' country, age, gender, the type of relationship and the main problematic substance had significant effects on the coping factors. Conclusions: A bifactor model related to coping behaviors is consistent with the theoretical assumptions of the general coping literature. The concept of a general coping factor also fits the theoretical assumptions of the stress-strain-coping-support model, with family members showing a general tendency to cope with the harmful circumstances which arise due to substance misuse. [ABSTRACT FROM AUTHOR]

Purpose: There is a virtual absence of previous research about the experiences of people affected by the presence of a substance misuser in the family in Brazil. Materials and methods: A diverse sample of 3158 (80.6% female) affected family members (AFMs) was recruited in the largest cities in all five Brazilian regions. A Brazilian Portuguese translation of a set of standard measures for the assessment of AFM stress, strain, coping, hopefulness and total family burden, based on the stress-strain-coping-support (SSCS) model, was employed. Results: Mothers and wives reported the greatest burden. Burden was also related to a number of other demographic and background variables, notably being higher for AFMs of lower socio-economic status and for those whose substance misusing relatives were currently receiving hospital treatment. Results offer some support for additive and moderation coping hypotheses, suggesting that greater engaged and tolerant-inactive coping add to stressful impact in the prediction of symptoms, and that lower engaged and tolerant-inactive coping in the face of relatively high stressful impact may be particularly useful in reducing symptom levels. Conclusions: This is the first national sample of AFMs to be studied in Brazil and the largest to have been reported from any country. The results should help build an emerging picture of how AFMs are affected and assist in planning services for AFMs. [ABSTRACT FROM AUTHOR]

This article is based upon the collective findings of a number of studies conducted in a number of countries during the past 20 years. Female partners and mothers are the family members who have been most represented in the study samples, but the latter also included sizeable numbers of male partners, fathers, sisters, brothers and adult sons and daughters. Citing examples taken from the studies, the article describes some of the most prominent elements of the stressful experience of living with a relative who is drinking or taking drugs excessively, notably: the relationship with a relative becoming disagreeable and sometimes aggressive; conflict over money and possessions; the experience of uncertainty; worry about the relative; and home and family life being threatened. The reasons why family members may put up with substance misuse are described, and the ways in which family members may either withdraw and gain independence or stand up to substance misuse, as alternative ways of coping, are outlined. Examples of the strain experienced by family members are given. The kinds of social support valued by family members are explained, as is the finding that good quality social support for family members is often lacking. The article concludes by offering an integrated view highlighting the disempowered position in which family members usually find themselves and the importance of good social support for family members in their coping efforts. Although the picture is coloured by factors such as sociocultural group and the ages and genders of family members and their relatives, we believe the core experience for affected family members is a universal one. [ABSTRACT FROM AUTHOR]

The 5-Step Method has now been evaluated in a number of studies in the United Kingdom and Italy. This chapter will present the evidence which summarizes how the intervention can help family members. The evidence is organized into two sections. First, quantitative evidence from feasibility and controlled studies in primary care, specialist services and community settings is summarized and discussed. Second, qualitative case study material is used to illustrate how the 5-Step Method can benefit family members. Finally, the chapter will draw together the conclusions which can be derived from the library of evidence which has been collected. It is concluded that when all strands of evidence are considered together, the 5-Step Method emerges as a very promising approach to reduce addiction family-related harm. The evaluation studies conducted to date provide a strong platform from which to roll-out the 5-Step Method in routine practice. [ABSTRACT FROM AUTHOR]

This article includes a description of the 5-Step Method. First, the origins and theoretical basis of the method are briefly described. This is followed by a discussion of the general principles that guide the delivery of the method. Each step is then described in more detail, including the content and focus of each of the five steps that include: listening non-judgementally; providing relevant information; exploring ways of coping; discussing social support and establishing the need for further help. Finally, issues of training, supervision and on-going support are discussed. It is concluded that the 5-Step Method offers a flexible response that can be delivered to family members affected by addiction problems by a range of helpers and in a range of settings and health systems. [ABSTRACT FROM AUTHOR]

An evaluation of a two-year project that aimed to move the practice of two specialist substance misuse treatment teams towards greater involvement of family members. Success was evaluated using a combination of: detailed process notes of all project meetings and events, collection of practice case examples, an inventory of new team procedures, individual interviews with team members, end of project focus groups, a final auditing of the involvement of family members, and completion of the attitudes to addiction-related family problems questionnaire (AAFPQ) before and after the project. Audit and AAFPQ data were also obtained from comparison teams. The conclusion is drawn that the project was successful in changing team practice in the desired direction: by the end of the project both teams were capable of acting as demonstration sites for family-oriented alcohol and drug problems treatment. The paper includes details of the family work conducted and its perceived benefits. Also discussed are the initial barriers to family involvement, a number of issues that remained unresolved, and the question of whether such changes are sustainable. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to explore the attitudes of staff working within mental health settings toward cannabis in general and cannabis use in individuals with severe mental-health problems. Method: Twenty members of staff working within community mental health teams in Birmingham, UK, were interviewed using qualitative research methods. The overarching themes within the staff accounts are described and the interrelationship between themes explored. Findings: Staff use an 'individualized' approach when working with cannabis-using clients dependent on a number of key components, including the positive and negative effects of use, wider evidence base, client vulnerability, engagement, professional and personal views and harm reduction. It is suggested that any approach staff may take toward cannabis use at any one time is greatly dependent upon the above factors and these factors are highly client specific. Conclusions: The findings may help to explain why interventions aimed at reducing substance use in people with psychosis might prove less successful when targeting cannabis use. [ABSTRACT FROM AUTHOR]

Background: Cocaine/crack-cocaine use is associated with a number of negative outcomes in people with mental health problems. Aims: To explore the extent of use in individuals with severe mental health problems and impact of client use on mental health service staff. Method: Following Graham et al. (2001), care coordinators within community mental health teams in Birmingham, UK completed a prevalence survey of cocaine/crack-cocaine use in clients on their current caseload to determine the extent of use. Findings were compared to those of Graham et al. Interviews with staff explored the impact of cocaine/crack-cocaine on client outcome and effects on staff within the teams under study. Results: An increase in cocaine/crack-cocaine use is reported (from 5.6% to 11.5% over 8 years). Interview data indicate that despite this increase, staff declare themselves more competent and confident in dealing with cocaine/crack-cocaine use. Conclusions: We propose that the integration of substance use treatment within mainstream mental health services is, in part, responsible for this finding. [ABSTRACT FROM AUTHOR]

Background: Family members affected by a close relative's substance misuse constitute a large but neglected, high-risk group. Interventions for that group are now being developed and tested in trials. More use should be made of qualitative methods to study process in such interventions. Design: Semi-structured interviews with family members 12 weeks after assignment to a full or brief 5-Step intervention. Both involved a primary care professional giving a self-help manual, and the full version also involved up to five sessions of a psychosocial intervention. Participants: 143 patients of GPs, health visitors and practice nurses in general practices in two areas of England. Patients were the family members of close relatives with drinking or other drug problems. Analysis: Framework analysis and grounded theory analysis of post-interview reports. Results: There was strong support for a form of intervention that involved face-to-face discussion with a primary care professional, and those who received the full intervention were appreciative of being able to talk to a professional who had time to listen and who appeared interested, understanding and caring. The self-help manual itself was reported to contain active ingredients for change, and a number of family members described transformations in their ways of coping with the problem whether they received the full or brief form of intervention. A common constellation of changes included increased consciousness of the nature and extent of the relative's drinking or drug use and its family effects, an acknowledgement of the family member's own needs and rights, a strengthening of resolve to assert plans and expectations, and a calming effect with reduction in stress symptoms. Many participants were unable to describe changes, however, and the following principal limitations of the intervention were described: prior familiarity with the material, perception that the intervention did not go far enough, belief that it was incapable of effecting change for the substance misusing relative, and a perception that sufficient professional expertise or sympathy was not always available in primary care. Conclusions: Findings suggest that the 5-Step family intervention has positive potential in the primary care setting, but has limitations and may need strengthening for family members whose problems are of longer standing or who have already been exposed to relevant information. [ABSTRACT FROM AUTHOR]

Aim: This study sought to develop a methodology to measure the integration of substance use treatment within five existing assertive outreach (AO) teams in Birmingham, UK. Changes in the way teams approach and discuss drug and alcohol problems amongst clients with severe mental health problems were anticipated. This was assessed at team meetings, through clinical sessions and case notes. The impact of change in team practice was also measured at the level of service users by assessing psychiatric symptoms, engagement, amount of substance used, and conviction ratings of positive substance-related beliefs.Method: Each team were provided with training and supervision to deliver cognitive behavioural integrated treatment (C-BIT). This aimed to increase awareness of the relationship between psychosis and problem substance use and provide skills to manage these difficulties. Data was collected at intervals over a 36 month period.Results: Staff within teams increased in self reported confidence and skills to deliver C-BIT and these gains were maintained over time. Findings suggest that following training, integration was achieved to a degree and changes in teams practice were observed. Improvements in client engagement and reduction in alcohol intake and positive alcohol-related beliefs were also noted but occurred regardless of team training.Conclusions: Training and supporting AO staff to use an integrated treatment approach is well received and produces lasting changes in confidence and practice. Whether this can go on to impact upon client outcome is yet to be established. [ABSTRACT FROM AUTHOR]

Aim To develop a model of change during and following professional treatment for drinking problems, grounded in clients’ accounts. Participants Subsets of consecutively selected clients of the UK Alcohol Treatment Trial (UKATT), followed-up at 3 months ( n = 211) and 12 months ( n = 198) after randomization. Location Five statutory and non-statutory alcohol problems treatment agencies in three areas of England and Wales. Data Open-ended interviews conducted according to a brief interview guide, leading to 400–800-word post-interview reports used for analysis (tape-recordings used for auditing purposes). Analysis Reports analysed by a team according to grounded theory principles, involving an iterative process with successive refinement of interviewing and analysis with each successive batch of data. Findings A model of change from the clients’ perspective was developed. Treatment was seen by clients as facilitating various changes in ways of thinking and/or increased support of various kinds from family and friends, along with new ways of acting in relation to drinking or more generally. For many those changes had led to an appreciation of the benefits accruing to them. Treatment was seen as part of a broader treatment system which included pretreatment assessment, forms of help additional to the trial treatment, plus an element of self-directed change during and following treatment. Taken with awareness of worsening alcohol-related harms, triggering events and external influence to seek treatment (the catalyst system), to which clients continued to refer following treatment, the change process is depicted as a complex, ongoing set of systems in which a trial treatment is embedded. Conclusions Models of change should be broadened so that treatment is seen as a complex system of parts, facilitating a nexus of cognitive, social and behavioural changes, embedded within a broader system of events and processes catalysing change. Such a model helps explain the relative absence of between-treatments outcome differences in UKATT and in the alcohol problems treatment and more general psychotherapy research literatures. [ABSTRACT FROM AUTHOR]

Aims 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. Design Includes cross-sectional and repeated-measurement studies. Setting and participants 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. Measurements 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. Findings 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. Conclusions 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. [ABSTRACT FROM AUTHOR]

Aims To explore, through the use of simple family diagrams constructed during personal interviews, the childhood families of young adult 'offspring' of parents with drinking problems and to compare them with those of nonproblem-drinking parents ('comparisons'). Design Cross-sectional interview. Participants Fifty 'offspring' and 50 'comparisons', aged between 16 and 35 years matched by sex and number of siblings. Data Quantitative data obtained through assigning values to bonds drawn on family diagrams, during semistructured interviews. Findings As predicted, 'offspring' diagrams indicated significantly less positive bonds between mother and father, between self and problem-drinking parent, and in the family as a whole; and no difference in terms of bonds between self and nonproblem-drinking parent. There were also significant differences, not predicted, with regard to bonds between siblings, which were less positive in the diagrams of 'offspring'. Distributions of key variables and example families suggested that considerable diversity exists in families that contain parental problem drinking. Conclusions Simple, easily obtainable family diagrams constructed in young adulthood may serve to encapsulate a considerable amount of data regarding childhood family relationships and cohesion. Families of offspring of parents with drinking problems may be comparatively deficient in positive aspects of family cohesion, although relationships with the nonproblem-drinking parent are mostly well preserved. One new finding that requires replication is that relationships between siblings, rather than receiving compensatory strengthening, are often adversely affected by having a parent with a drinking problem. [ABSTRACT FROM AUTHOR]

The excessive appetite model of addiction is summarized. The paper begins by considering the forms of excessive appetite which a comprehensive model should account for: principally, excessive drinking, smoking, gambling, eating, sex and a diverse range of drugs including at least heroin, cocaine and cannabis. The model rests, therefore, upon a broader concept of what constitutes addiction than the traditional, more restricted, and arguably misleading definition. The core elements of the model include: very skewed consumption distribution curves; restraint, control or deterrence; positive incentive learning mechanisms which highlight varied forms of rapid emotional change as rewards, and wide cue conditioning; complex memory schemata; secondary, acquired emotional regulation cycles, of which 'chasing', 'the abstinence violation effect' and neuroadaptation are examples; and the consequences of conflict. These primary and secondary processes, occurring within diverse sociocultural contexts, are sufficient to account for the development of a strong attachment to an appetitive activity, such that self-control is diminished, and behaviour may appear to be disease-like. Giving up excess is a natural consequence of conflict arising from strong and troublesome appetite. There is much supportive evidence that change occurs outside expert treatment, and that when it occurs within treatment the change processes are more basic and universal than those espoused by fashionable expert theories. [ABSTRACT FROM AUTHOR]

Presents selected and edited abstracts from the Society for the Study of Addiction Annual Symposium on November 4-5, 1999 in Edinburgh, Great Britain. `Altering American Treatment Professionals' Attitudes Toward Harm Reduction,' by Perilou Goddard; `Shared Care, Shared Success!,' by Rob Kenyon; `Trends in Treated Opiate Misuse in Dublin: The Emergence of Chasing the Dragon,' by Bobby P. Smyth, Mary O'Brien and Joe Barry.

This paper outlines an eight-fold typology of coping actions based upon a qualitative analysis of the accounts provided by 50 close relatives of people with drug problems. In a number of different ways relatives draw attention to the contrasts between these distinguishable ways of coping. Emphasis is placed upon the provisional nature of this typology and upon the compromises between, and combinations of, ways of coping that are often used by relatives in practice. Different ways of coping represent alternative choices for relatives, often explicitly expressed by them as difficult dilemmas. Links are suggested between the ways of coping identified here and those discussed in the literature on coping with other disorders and disabilities in the family, with ways of coping described in the general literature on coping with stress, and with types of social action appearing in general models of interpersonal behavior,. Implications for counseling close relatives of people with drug problems are also outlined. [ABSTRACT FROM AUTHOR]

Each member of a sample of 59 men admitted to one London alcoholism halfway ho use was interviewed concerning the details of his social and drinking history. Analysis suggested the existence of two major dimensions of individual variation: degree of chronic alcohol dependence, and late-uncomplicated versus early-complicated alcohol dependence. Observation of the lengths of residence and manners of discharge of members of the sample suggested two varieties of failure; premature discharge (length of stay less than two months) and irregular discharge (drinking at discharge and/or discharge to an unknown or unsatisfactory destination) 4 There was a significant tendency for early-complicated alcoholism to be associated with premature discharge. [ABSTRACT FROM AUTHOR]

One hundred and sixty-four 16-35-year-old offspring of parents with drinking problems, recruited from a variety of clinical and community sources, were compared with 80 respondents of similar ages from similar sources who did not have parents with drinking problems. Each was interviewed using a semistructured interview. Adult adjustment was similar in the two groups, but the offspring of parents with drinking problems did report considerably more disharmony in their families of origin, and many more childhood difficulties. Factor analysis of the adult adjustment data for the samples combined showed four factors which accounted for 41% of the variance; these factors differed little in their effect in the two groups. The groups' reports of the drinking problems of their siblings, however, suggests that this sample might be unrepresentative of the true risk to the children of parents with drinking problems for the development of alcohol-related (although not other) difficulties in adulthood: 16% of this group reported a sibling with a drink problem and a further 9% were unsure, but only one member of the comparison group reported a sibling with a drink problem, and one was unsure. Path analysis showed that both parental problem drinking and family disharmony are related in complex ways to adjustment difficulties in adulthood. 'Demoralisation', the largest of the four factors, was particularly related to disharmony in the family of origin: in the absence of disharmony, offspring versus comparison status was negatively correlated to demoralisation in adulthood, suggesting that having a parent with a drinking problem might sometimes be a strengthening experience. [ABSTRACT FROM AUTHOR]

Editorial. Explores the role of families and social networks in the course of addiction problems. Improvement in both substance-related outcomes and family functioning; Influence of the social environment in supporting either continued problem drinking and abstinence; Barriers to family involvement in addiction treatment.

Discusses the psychological issues pertaining to dependence. Use of dependence on alcohol as an illustration of what the author would most like to know; Pros and cons of drinking; Social reaction.

The author comments on a research about the influence of alcohol in social cognition. It mentions that the characteristic impairment in anterograde memory function, which is sometimes a precursor to the onset of frank Korsakoff syndrome may be associated with subtle changes within mammillary bodies, thalamus and related diencephalic-thalamic structures. Moreover, it mentions that problems in social cognition on alcohol misuse may lead to discomfort and stress in social situations which may predispose in turn to alcohol consumption and relapse. It gives comment on the issue that heavy drinkers commonly get into fights and commit violent or acquisitive offenses while under the influence of alcohol.

The article comments on the paper "Allocating treatment options to patient profiles: clinical art or science?," by Gerhard Buhringer in a 2006 issue. The paper makes a valid point in questioning the validity of the belief that after Project MATCH, client-treatment-matching can no longer be used. However, Buhringer failed to provide a more radical suggestion for the future of treatment research.