Evaluating a Program for Concerned Family Members of Individuals with SUDs

Substance use disorders (SUDs) have been noted to have a substantial and detrimental impact on concerned family members (CFMs). This population—including parents, siblings, and spouses—reported a wide range of health-related issues attributable to their loved ones’ substance misuse, including psychopathological symptoms, chronic pain, headaches, fatigue, substance abuse, heart disease, diabetes, and asthma (Chassin, Pitts, DeLucia, & Todd, 1999; Lee et al., 2011; Hudson, Kirby, Clements, Benishek, & Nick, 2014; Merikangas et al., 2009; Montgomery & Johnson, 1992; Orford et al., 2005; Ray, Mertens, & Weisner, 2007). They also frequently reported a hostile home environment plagued with domestic violence and criminal behavior directed in and outside of the family (Hines & Douglas, 2012; Kahler, McCrady, & Epstein, 2003; O’Farrell, Van Hutton, & Murphy, 1999; Stuart et al., 2013; Stuart, Moore, Kahler, Ramsey, & Strong, 2004). As comorbid disorders have been associated with greater substance abuse and poor treatment outcomes in substance users (Drake, Mercer-McFadden, Mueser, McHugo, & Bond, 1998; Grella, Hser, Joshi, & Rounds-Bryant, 2001; Mulsow, 2007; Randall, Henggeler, Pickrel, & Brondino, 1999; Weisner, Parthasarathy, Moore, & Mertens, 2010), it should come as no surprise that the combination of substance use and concurrent disorders (SUCDs) has been associated with substance abuse and psychopathological problems in CFMs (Ohannessian et al., 2004).

Despite increasing knowledge of the impact of SUCDs on CFMs, there has been a limited initiative to develop and implement treatment protocols for this population. For example, policies encouraging research and promoting treatment efforts targeted specifically towards CFMs only started to become prominent in the 2000s, and primarily in the United Kingdom (Velleman, 2010). However, there is a body of research that has targeted the potential causes of such complications within CFMs. For instance, CFMs reported a high level of subjective personal stress associated with financial, interpersonal, familial, and legal problems (Benishek, Kirby, & Dugosh, 2011; Lee et al., 2011). In addition, CFMs reported feeling isolated and perceiving less support from their social networks (Kahler et al., 2003). They also reported a greater amount of intrafamilial, dyadic conflict between substance users and their partners, which are subsequently witnessed by their children (Randall et al., 1999). Recently, Orford, Copello, Velleman, and Templeton (2010) conceptualized the stress-strain-coping-support model (SSCS), which explains how the effects of SUDs on stress, social support, and family cohesiveness could translate into physiological and psychological distress and health impediment. This model holds that SUDs impede CFMs’ quality of life and biopsychosocial health by increasing stress and strain on the CFMs. This model also theorizes that their social support networks (e.g., family and friends) will determine their ability to overcome these stressors and cope with the progression and treatment of the SUCD. They subsequently developed the five-step method, targeting such factors outlined in the SSCS model, which has been successful in helping CFMs cope with SUDs within their families, reduce psychological distress within CFMs, and reduce physical complaints in primary care settings, specialist services, and community settings (Copello et al., 2009; Copello, Templeton, Orford, & Velleman, 2010a, 2010b; Velleman et al., 2011).

However, such treatment efforts have not addressed the additional strain and specific circumstances arising with concurrent disorders to the SUD. The current study looked to share the efficacy of a psychoeducational treatment program that addressed the effects of SUCDs on CFMs in an effort to improve quality of life and coping capabilities throughout the progression and, potentially, treatment of the SUCDs. In particular, we assessed how this treatment program and efforts to address the effects of SUCDs reduced the resulting stress and strain, as well as how such efforts could improve family functioning and perceived social support from friends and family. Furthermore, we assessed the degree to which the effects of the treatment program were resilient to time-dependent decay at a six-month follow up, as a means of understanding how permanent these benefits and improvements were.

Treatment Plan

The program was premised on three principles:

The first was that CFMs are affected by the SUCD, and this in turn affects the course of the SUCD.

1. The second was that CFMs require assistance in their own right to sort out the effects of SUCDs on their lives. With the right information and a supportive environment, family members would be equipped to make the best decisions for personal situations.
2. The third premise was that assistance, support, group accountability, and friendship would improve through coping with the SUCD by counteracting feelings of shame and isolation.

The program had several goals, including helping participants recognize and understand how they and other family members have been affected by SUCDs; encouraging and assisting participants to identify personal needs and formulate directions for the future; providing education and information about SUCDs; equipping CFMs with the right information about SUCDs and recovery in order to feel prepared to make decisions that suit them; assisting CFMs in developing effective coping strategies; creating an atmosphere of trust and safety in a group therapy format so participants receive the support they need to discuss their concerns and break down feelings of isolation. The program thus assisted CFMs in regaining and maintaining their sense of well-being, whilst providing them with options and resources.

The family program consisted of four consecutive, structured days of programming followed by six weekly aftercare sessions in a closed group environment. This program was repeated six times yearly and had both a treatment manual and participant manual in order to provide identical programming in each repetition. The program consisted of five phases. In the first phase, participants attended the SUCDs family program orientation session, which consisted of a lecture introducing the program; outlining the program’s understanding; and providing information on SUCDs, mental health, early recovery issues, how family members are affected by substance use, the structure of the SUCD family program, and other services available to family members. The second phase consisted of an assessment of CFMs by SUCD physicians. In the third phase, participants attended the intense group therapy portion of the program throughout four consecutive days, Monday to Thursday, from 9 AM to 5 PM. This included:

• Facilitating the group to enhance feelings of security and provide a safe place for group members to discuss their experiences and how they have been affected by their relatives with SUCDs
• Attending psychoeducational lectures and discussions on communication, setting boundaries, problem solving, and coping strategies such as strategies for dealing with manipulation
• Attending psychoeducational lectures and discussions to increase participants’ knowledge of SUCDs and problems accompanying substance use, including family dynamics, family roles, and relationships (lectures were provided by two facilitators of the program and two physician guest speakers)
• Allowing opportunities (in a safe group environment) for group members to sort through and grieve the emotional impact the SUCDs of their relatives have had on them and other family members
• Viewing films and discussing the films as part of therapy
• Introducing participants to potential self-care strategies such as leisure activities and physical and relaxation exercises

Following this initial group therapy component of the program, participants attended weekly, two-hour, closed group sessions for five to six weeks. This fourth stage included:

• Facilitating group cohesion, group discussions, and individual members updating other group members on how they coped for the week that passed
• Facilitating consolidation of new initiatives of the group members, such as setting a new boundary identified in the four-day phase of the program to be followed through into the aftercare sessions, as well as new behaviors or changes made to family roles and dynamics
• Providing further information about the recovery process from SUCDs
• Facilitating a cognitive behavioral therapy (CBT) exercise focused on managing anxiety and worry
• Consolidating work by group members on their codependent relationship patterns
• Viewing films to increase participants’ knowledge of the physiological components of substance use and how use affects and changes the brain
• Upon further consolidating social support within the group and recognizing the group accomplishment of completing the family program, a potluck is facilitated
• Handing out and explaining client satisfaction questionnaire packages to the group participants

The final phase of the program involved an exit interview summarizing the program and informing participants of additional resources in the community for any additional needs.

Method

Data was collected through multiple runs of the treatment program taking place between 2006 and 2014. Prior to the start of each program, individuals with SUCDs and their families were invited to attend a lecture on SUCDs. On their arrival, clients and their families were introduced to the study. Following the lecture, the social worker in charge of the treatment program contacted all attendants of the lecture and requested their participation in the program. Those who chose not to participate in the program were called again by a research assistant to request their participation in the comparison group. The social worker was not aware of which lecture attendees were study participants. There were no exclusion criteria for the treatment program, however, participants were only included in the analyses if the battery of questionnaires was completed in its entirety.

The treatment group completed the first battery of questionnaires as a baseline measure on the first day of the treatment program, while the comparison group had the battery of questionnaires sent to them once they agreed to participate in the study (T1). At the end of the treatment program, which was roughly six weeks in length, treatment participants completed the same battery of questionnaires for a second time, while the comparison group were once again sent the battery of questionnaires (T2). Six months later, all participants were sent the battery of questionnaires for a third time (T3). The treatment group completed a perceived personal benefits questionnaire at the end of the program.

Participants were assessed with the Index of Clinical Stress (ICS; Abell, 1991), the Perceived Social Support-Family and Perceived Social Support-Friend scales (PSS-fa & PSS-fr; Procidano & Heller, 1983), and a brief version of the Family Assessment Measure (FAM-III; Skinner, Steinhauer, & Santa-Barbara, 1995). The ICS, a twenty-five-item scale with scores ranging from zero to one hundred, was used to assess subjective personal stress and problems associated with this stress (Abell, 1991). The PSS scales were each composed of twenty items assessing the subjective perception of social support from family and friends. Scores ranged from zero to twenty, with higher scores indicating stronger social support (Procidano & Heller, 1983). Brief versions of the FAM-III subscales were utilized to assess family functioning: the Brief General Family Functioning subscale (BGFF) assessed overall functioning and cohesiveness within the family; the Brief Dyadic Family Functioning subscale (BDR) assessed the relationship between the participants and the substance-using individuals; and the Brief Self-Rating subscale (BSR) measured an individual family member’s perception of the overall functioning and conflict within the family (Skinner et al., 1995). These scales were composed of fourteen items, with lower scores on these scales indicating greater familial functioning. Finally, participants answered ten questions on the perceived personal benefits of the treatment program. This was based on participants’ quality of life, how much they learned about SUCDs, whether their coping mechanisms to challenges arising as a function of the SUCD in the family have improved, and whether their family cohesiveness has also improved.

Results

Of the 145 participants in the program evaluation, ninety-seven were in the treatment group. The sample had a mean age of 52.92 (SD = 10.85) and was by majority female, married, reported the most frequently abused drug by the family member was alcohol, and that the SUCD had been a problem for an average of 7.89 (SD = 7.17) years. When assessing responses from the aftercare follow up (six months [T3]), only sixty (48.8 percent) completed the third battery of questionnaires (treatment group n = 44). This subsample had a mean age of 53.39 (SD = 10.33) and was by majority female, married, reported that the most frequently abused drug by the family member was alcohol, and that the SUCD had been a problem for an average of 7.62 (SD = 7.24) years.

At baseline (T1), the treatment group reported a significantly higher level of subjective personal stress, perceived less social support from family, and reported greater dyadic familial dysfunction and greater self-rated overall family dysfunction. We then assessed the effects of the treatment program with an elaborate multivariate analysis of variance on ICS, PSS-fa, PSS-fr, BGFF, BDR, and BSR scores, followed by a simple effects analysis with posthoc pairwise comparisons with a Bonferroni, family-wise, error-corrected threshold. We found that, when assessing changes between the start (T1) and the end (T2) of the treatment program, there were significant interactions between time (six weeks) and group (treatment vs. comparison) effects on ICS and PSS-fr scores, and group had significant main effects on ICS, PSS-fa, BGFF, BDR, and BSR scores. Posthoc analyses revealed that, between T1 and T2, the treatment group alone reported a decrease in subjective personal stress, an increase in perceived social support from friends, an improvement in the dyadic relationship between the participants and the individuals with an SUCD, and an improvement in self-rated overall family functioning. Among the comparison group, on the other hand, we observed an improvement in general family functioning that was independent of the treatment program.

Next, we conducted a similar set of analyses among participants who completed the third set of questionnaires (T3). The group had a significant main effect on ICS and BDR scores. However, in contrast to the prior set of analyses, there were no significant interactions between time (six months) and group effects on any of the measures. Posthoc analyses revealed that the only significant change observed was a significant decrease in subjective personal stress between T1 and T2, and between T1 and T3, among the treatment group. There was no significant change in stress between T2 and T3, nor was there any significant change between any timepoints in any other dependent measures, and no differences were observed in the comparison group.

Finally, we ran descriptive statistics to assess responses to the personal benefits questionnaire, which was completed by one hundred treatment participants. The vast majority of the participants (at least 80 percent) reported having an increased knowledge about SUCDs; an improved ability to work through emotional difficulties related to addiction within the family; an improved ability to work through emotional difficulties related to their relationships with addicted family members; are now able to work through the emotional difficulties related to their relationships with other family members affected by addiction; and have successfully reduced the amount of caretaking, perfectionism, worrying, codependency, overworking, and people pleasing. In addition, 50 percent reported participating in more leisure and enjoyable activities, and 57 percent felt more comfortable rejecting activities that were not enjoyable to themselves. Lastly, approximately 38 percent reported an improved expression of feelings and communication towards the family members with SUCDs.

Conclusions

According to our results, psychoeducational treatment protocols targeted towards CFMs of individuals with severe SUCDs could significantly improve quality of life and overall health by ameliorating factors specified in the SSCS model. This treatment program was found to significantly improve family functioning and perceived social support as well as reduce stress. When assessing the persistence of such effects, reductions in stress were found to persist six months after conclusion of the treatment program. Finally, participants of the treatment program reported improvements in coping methods and capabilities, as well as in communication within their families and with the individuals with a SUCD.

These factors are pertinent to CFMs’ quality of life and biopsychosocial health due to their relationship with physical and psychological well-being. To elaborate, stress has been associated with a number of psychological and physical pathologies, including major depressive disorder, influenzas, autoimmune diseases, chronic inflammatory diseases, cardiac diseases, cancer, and chronic pain (Anisman, 2014). Therefore, reductions in stress could be protective towards pathological consequences of chronic stress arising due to the SUCD. Furthermore, a strong sense of social support and family functioning have been noted to aid coping with a variety of stressors and promote healthy behaviours and predict greater cognitive, emotional, physical, and social health (Ali & Malik, 2015; Cavaiola, Fulmer, & Stout, 2015; Eack, Newhill, Anderson, & Rotondi, 2007; Eom et al., 2013; Kara & Açıkel, 2012; Krokavcova et al., 2008; Lavee & Olson, 1991; McDowell & Serovich, 2007; Vogel et al., 2012; Yilmaz, Bal, Beji, & Arvas, 2015). This was one of the central tenets of the SSCS model (Orford et al., 2010) in that social support will be a strong determinant factor of CFMs’ ability to cope with the chronic stress and strain invoked by SUCDs. Therefore, by improving communication and overall family cohesiveness, functioning, and perceived social support, psychoeducational treatment targeted towards CFMs could help them cope with the chronic stress and strain of the SUCD throughout the progression and remission of the SUCD, and therefore protect them from any potential pathological consequences resulting from this stress and strain.

It is also worth noting that targeting CFMs specifically can continue to have treatment implications for SUCDs. In a study by Velleman et al. (2011), CFMs participating in a treatment program utilizing the five-step method reported a gradual improvement in their relatives’ misuse of an addictive substance, demonstrating that the amelioration in the quality of life of family members could have implications on the use of individuals with SUCDs.

To summarize, we demonstrated that psychoeducational treatment efforts targeted towards CFMs of individuals with severe SUCDs could yield highly beneficial results for their mental and social well-being as well as family functioning. These effects have a number of beneficial implications for their overall health, quality of life, coping with SUCDs, and the treatment of SUCDs themselves. Encouraging the implementation of such programs for CFMs around the globe could be a strong asset when targeting substance use issues throughout the community and the detrimental social impact of SUCDs.

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Editor’s Note: This article was adapted from an article by the same authors previously published in the Journal of Substance Abuse Treatment (JSAT). This article has been adapted as part of Counselor’s memorandum of agreement with JSAT. The following citation provides the original source of the article:

Denomme, W. J., & Benhanoh, O. (2017). Helping concerned family members of individuals with substance use and concurrent disorders: An evaluation of a family-member-oriented treatment program. Journal of Substance Abuse Treatment, 79, 34–45.