A national newsletter on substance misuse management in primary care NETWORK
Practitioners can feel they lack the skills to work with families. John Westhead takes us through some of the basics to improve the service we provide. Ed.
Substance misuse in the family – how to help
to know, give relevant information, and then elicit how they might use this information 5
. Vellememan4 describes three common responses to substance use
in the family. The first is to engage the user in an attempt to deal with the problem often involving throwing alcohol away or using active attempts to prevent their use of drugs. This can give the family member a sense of doing something, but on the other hand may lead the user to become more secretive and to experience increasing resentment. The second response is to tolerate the drinking, but attempts to manage their use in such a way that reduces the social embarrassment, reduces the risk to the user and minimises the impact on the rest of the family. This might include buying the substance for them. Tolerating the drinking can be seen as pragmatic and a way of reducing arguments, but can also lead to resentment amongst family and friends as they come to feel they are being used to support the habit. The third strategy is to withdraw from the user to minimise the impact on their own life and allow the person to experience the negative consequences of their own behaviour. Withdrawing from the user can protect the family to some extent and may produce a positive reaction from the user, but it might instead increase the sense of abandonment by the user, and make it more difficult to resume family roles on stopping use, as the family has learnt to function without them.
When supporting those affected by other people’s substance misuse, it is important to adopt a positive attitude, to recognise that they have considerable expertise in responding to their family member and that the actions of the family are seen as the best efforts to manage the situation1
that sometimes their attempts to deal with use by loved ones can compound the problem2
. Be clear about confidentiality with families3
and remember that listening and advising families does not mean sharing confidential information about the individual user. Avoid any attempts to be drawn into taking sides or arbitrating within families4
Remember that people around the user might also be drinking or using themselves and that they too will have a whole variety of attitudes towards substances.
From the perspective of those in the support network, they are often desperate for help and yet uncertain about how they should respond to the substance use. If they have known the person before they used they are often grieving for the person they knew. At the same time the person is still part of their life and the family often think they could “return” to them if they chose to stop using problematically. Using is often perceived as a personal rejection by those around the user, so anger is often mixed with sadness and hurt.
Professionals can perform a valuable task simply by listening, though “opening up” for family members can be difficult, especially if they have received unhelpful advice elsewhere. Once a clear understanding of the situation has been developed it might be appropriate to give information about effects of and treatments available for the user. When giving information elicit what they want
1 Falloon, I. R. H., Fadden, G. Mueser, K. Gingerich, S., Rappaport, S., McGill, C., Graham-Hole, V. and Gair, F. (2004) Meriden Family Work Manual (3rd Meriden West Midlands Family Programme
2 Copello, A. ,Orford, J., Velleman, R.,Templeton, L .,& Krishnan, M. (2000). Methods for reducing alcohol and drug related family harm in non-specialist settings. Journal of Mental Health, 9: 3 329–343
3 O’Farrell, T. J. and Fals-Stewart, W. (2006) Behavioural Couples Therapy for Alcoholism and Drug Abuse, London, The Guildford Press
4 Velleman, R. (2001) Counselling for Alcohol Problems (Chap 10), London, Sage 7
Support networks might try all three strategies over time and an opportunity to examine the pros and cons of each approach might provide a valuable chance to think through some of the conflicts for the family member. A shift in strategies might not be easy for a person as their existing approach might be supported by much wider beliefs about family relationships, their culture, their own self-esteem and their assertiveness skills.
. Recognise that families do not cause people to use, but
Many treatment approaches focus around encouraging the family to communicate clearly and positively and actively coach the family in the use of clear communication skills such as listening to each other, making positive requests, problem solving and expressing feelings in a non-confronting way 1,4,6
. When used well, these communication
skills can reduce the stress levels in the family, thereby reducing the likelihood of relapse.
Both users and their social networks can be helped by identifying and utilising other people who can support them. This might mean contacting both old and new supports and sometimes professionals can enhance this by discussing who might be helpful and how best to contact them7,8
. Remember that Al Anon, Families Anonymous
and Adfam offer valuable support to many families, and that Alcoholic Anonymous and Narcotics Anonymous offer a useful support, especially if the user lacks any non-drinking social contacts. Involving social networks has also been found to increase the success of substance misuse treatment, by helping families support treatment goals, involving families in relapse prevention work and making abstinence more rewarding6,9
John Westhead, Senior Lecturer in Mental Health Nursing, Staffordshire University
5 Rollnick, S., Miller, W.R. and Butler, C. (2008) Motivational Interviewing in Health Care: Helping Patients Change Behaviour, London, The Guildford Press
6 Copello, A., & Orford, J. (2002). Alcohol and the family: Is it time for services to take notice of the evidence? [Editorial], Addiction, 97, 1361–1363
7 Graham H. L. (2004) Cognitive-Behavioural Integrated Treatment, (C-BIT) A Treatment Manual for People with Severe Mental Health Problems, Chichester, John Wiley and Sons, Ltd.
8 Orford, J., Hodgson, R., Tober, G., Barrett, C.(2002) Social Behaviour and Network Therapy: Basic Principles and Early Experiences, Addictive Behaviours, 27 345 -366
9 Miller, W.R., Meyers, R.J. and Hiller-Sturmhofel, S. (1999) The Community Rein- forcement Approach, Alcohol Research and Health, 23 (2) 116 – 120
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