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Families and addiction:
Stress, symptoms and coping
responses
Professor Alex Copello
Birmingham and Solihull Mental Health
Foundation Trust and
University of Birmingham, UK

Families First – DDN, Adfam Conference
Birmingham, Holiday Inn, 15th November 2012

…it ought to be both surprising and shocking
that there has been so little in the way of a co-
ordinated response to families living with the
drug problem of their son or daughter, brother
or sister.

Marina Barnard
Drug Addiction and Families
2007, p. 51

Individual vs. social view
of addictions

Despite the available evidence and
potential gain, shifting the
emphasis from individualised
treatment approaches to those
focused on the substance user’s
family and social environment
presents a number of significant
challenges
(Copello, 2006)

A narrow individual focus on treatment
and help fails to consider some well
proven facts:
• That living with a significant alcohol or drug problem is a
highly stressful experience
• That the stress experienced leads to physical and
psychological symptoms for family members
• That family members use generic and primary care services to
seek help
• That family members provide significant care (e.g. UKDPC)
• That family members can improve outcomes for the
substance user

BARRIERS...

to recognition and

to accessing formal and
informal support

Why work with families?
1. ‘Carer burden’ is extremely high and families need support in
their own right

• Costs are financial, social, psychological, physical and
relational
• Reciprocity of well-being
• Families indirectly influence relatives’ using behaviour
• We need to consider the whole system of the family, not just
the individual when thinking Recovery.

Why work with families?

2. Improved client treatment outcomes

• Increases client entry into treatment
• Improves engagement and retention of client in
treatment
• Improves substance use outcomes for clients
• Reduces relapse
• Families play crucial role in facilitating recovery

The four most important people: how were
they related to the drinkers?
This graph shows how the participants were related to their four most
important people. Frequencies of relationship type are shown for the 1st, 2nd,
3rd and 4th most important people to the drinker.
500

400 significant other
frequency

300 family

200 friend

100 other

0
1 2 3 4
im portant person no.

The majority of people entering alcohol treatment named their partner as the
most important person, although family members were also a popular choice.
Very few drinkers named their partner as least important person of the four.
Members of close family were predominantly named as second or third most
important, and friends were commonly named as third or fourth.

How large is the problem?

It is estimated that there are approximately 15 million people
with drug use disorders globally and 76 million with alcohol
use disorders (Obot, 2005).

A cautious estimate of just one person seriously affected in each
case suggests a minimum of 91 million affected family
members

Most people would use a greater multiplier and produce a
higher figure

What is the extent of the problem?
• Key findings from UK DPC study
about adult family members of
Drug treatment General drug misusers.
population population
• What about alcohol misuse?
• Up to 1 million children are
affected by parental drug misuse
50,373 partners 573,671 partners & up to 3.5 million by parental
55,012 parents 610,970 parents alcohol misuse (Manning et al.,
35,208 ‘other’ 259,133 ‘other’ 2009).
• It is estimated that the impact of
drug misuse on the family costs
the UK £1.8 billion but also
Total = 140,593 Total =1,443,774 brings a resource saving to the
NHS of £747 million through the
care provided.

An International Picture
• We have spoken directly to family members in:
– England
– Mexico City
– Australia (Aboriginal communities)
– Italy
• What we have been told suggests that the impact of
substance misuse on the family is remarkably similar all
over the world.
• Yet, particular elements of this experience can differ or
be more prominent according to culture and social
context.
• This experience seems to be similar to people who live
with other traumas.

Main Modifiers of the Core Family
Member Experience
Family Material FM female
circumstances or male

Relationship
Traditional vs THE CORE
to misusing
Modern family EXPERIENCE relative
roles

Is modified
by

Substances use Culture:
pattern individual, familial
or
communal
Licit or illicit:
traditional or
recently
introduced

THE UNIQUE SET OF STRESSFUL CIRCUMSTANCES FOR
FAMILIES COPING WITH ADDICTION

 Has the nature of severe stress, threat and abuse
 Involves multiple sources of threat to self and family, including emotional, social,
financial, health and safety
 Can have significant impact on children
 Worry for that family member is a prominent feature
 There are influences in the form of individual people and societal attitudes that
encourage the troubling behaviour
 Attempting to cope creates difficult dilemmas, and there is no guidance on the
subject
 Social support for the family is needed but tends to fail
 Professionals who might help are often at best badly informed and at worst critical

Symptoms of Ill Health
Family Family members; psychiatric out-pts. and
members community controls

35
30
25
20
15
10
5
0
UK

Wives

Control
Mexico

P.Care

P.Care

Psych
1

2

Ray et al (2007)

Compared family members of people with substance misuse problems with
family members of similar persons without substance misuse.

Samples:
Family members n = 45,677 (male/female – 46/54%)
Comparison group n = 141,722 (male/female – 46/54%)

More likely to be diagnosed with medical conditions most commonly
depression and other psychological problems

Ray et al (2007) The excess medical cost… Medical Care

Three Common ways of
responding

‘Putting up with it’

‘Standing up to it’

‘Withdrawing/Independence’

Practice

► Some very good examples of services for
family members but provision is patchy

► Implementation of evidence based
practice is low

► Potential to improve availability and
response to families

We know that family members have
two related needs:

To receive advice and support on their
own right

To be supportive of the relative’s
treatment and involved if useful

“Being there”
“Give advice”
“Being a strength”
“Day to day”

“Continuity of support”
“Your time”
“Understanding”
“Challenges”

5-Step Method
• 1 – Listen, reassure and explore concerns
• 2 - Give relevant targeted information (eg
substances, treatment, support)
• 3 - Explore coping responses – ‘engaged’,
‘tolerant’, ‘withdrawn’
• 4 – Discuss social support – map
• 5 – Discuss further support needs

TRANSFORMATIONS DESCRIBED BY FAMILY MEMBERS
RECEIVING 5-STEPS IN PRIMARY CARE

• Increased focus on own life and needs (gaining
independence)
• Increased assertiveness over the misuse (resisting
and being assertive)
• Taking a calmer approach towards the misusing
relative (reduced emotional confronting)
• Increased awareness of the relative’s misuse
problem and its effects on family members
(cognitive change)

Key message:

A little support can have wide
positive consequences

But most important:

Seeing family members as partners in the challenging
task of helping people change addictive behaviours

UKDPC research on adult family /carers

Phase 2: 2011-12
Aims
•To describe the extent and nature of support provision for adult
family members / carers of people experiencing drug problems to
highlight gaps and good practice to help improve provision.

Components:
•Review of policy & guidance in the UK
•Web survey of service providers in the UK
•In-depth study: 20 DAT areas in England & 8 ADPs in Scotland

Research team: Alex Copello, Lorna Templeton, Gagandeep Chohan &
Trevor McCarthy

2

Policy review findings
[Note: Unpublished – please do not quote without permission]

• Increased level of recognition of families in policy & guidance

BUT

• ‘Families’ generally = children of substance-using parents

• Little consideration of sub-groups of adult family members &
their varying needs

• More focus on involvement in treatment than help in own right

• Lack of detail on what needs to be provided

• Little consideration of monitoring quality or extent of provision

• Need more recognition in strategies in related policy areas (eg
criminal justice; DV).

3

Web survey findings

Characteristics of services
•253 services from across the UK (70% non-statutory)
145 - England
71 - Scotland
22 - N Ireland
14 - Wales

•Type of service
58% = Part of service for substance misusers
24% = Service solely for adult family members
10% = Part of generic carers service
8% = Other

•Who worked with
89% = Drugs and alcohol59% = Families alongside drug users
11% = Drugs only 41% = Adult family member only

3

Web survey findings

Support to family members on their own

Counselling 48%
Bereavement 29% Co-dependency-based 22%
5-step method 9%
12-step support 7%
CRAFT 1%
PACT (1)
Family therapy (1)

3

Web survey findings

Support for family members and drug users together

3

Areas for action

• Improve needs assessment
– different groups;
– different needs; and
– basic prevalence.

• Develop targets and outcome assessment
– to enhance provision; and
– demonstrate value and build evidence base.

• Promote the evidence
– for what is needed; and
– what works.

• Workforce development - specialist and generic.

3

Concluding thoughts: a case of global
public health neglect?

• A significant public health problem.
• The impact and cost of the care given by family members is
significant.
• Alcohol and drug policies are increasingly recognising the needs
of family members or how they can be involved in treatment.
• Service delivery remains predominantly oriented towards the
focal alcohol or drug client, although there is evidence of a
wide range of interventions to support families, and some
evidence that more services are becoming available.
• An effective response to the needs of family members has the
potential to significantly reduce harm and health problems in
this group

Thank you for ��ٱ�Ծ��Բ�…

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Adfam- AlexCoppelloPP

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