The development of Families CARE

From the Introduction to Families CARE: Helping Families Cope and Relate Effectively Facilitator’s Manual

Background

In 1997, the Centre for Addiction and Mental Health (CAMH) opened the Family Addiction Service (FAS) to meet the needs of family members of people with substance use problems. Since then, FAS therapists have worked with family members both individually and in groups.

Initially the group program was primarily supportive, but over time it began to address particular topics, such as self-care, boundaries and hope. Various groups were run at different sites, by different therapists, with different topics and in different ways. Following most educational evenings or series of groups, staff elicited written feedback from the clients.

In March 2006, the FAS hired a psychologist to help review, refine, consolidate and manualize the group programs being offered. This psychologist:

• observed some of the educational evenings and groups, as well as similar groups offered in other programs
• read the feedback forms from family members, which provided information on what they believed was helpful about their treatment and what they wished could have been different
• solicited feedback from the therapists who facilitated the groups and educational evenings (through surveys, interviews and group discussions) and from FAS board members
• reviewed research articles and books on treatment relevant to the support offered in the FAS, looking specifically for empirically validated approaches that could be adapted to the needs of the FAS’s clients.

Priorities

For a year after this initial process, the FAS team expanded the program, incorporating material from a variety of sources. This program development was based on the following priorities:

• using empirically validated treatment
• meeting the needs of our diverse clientele
• providing support
• facilitating skills development
• providing education.

Each of these areas is discussed below.

Using empirically validated treatment

Two of the treatments best validated by empirical data are Community Reinforcement and Family Treatment (CRAFT; Stanton, 2004), a cognitive-behavioural treatment program designed to help partners or other family members to enter treatment; and behavioural couples therapy (O’Farrell & Fals-Stewart, 2003), a behavioural treatment program for both partners.

Like these two programs, we chose to use a cognitive-behavioural approach with our family members.

Meeting the needs of our diverse clientele

We had to develop a program that could be useful for various types of family members (e.g., partners, adult children, parents, siblings, close friends, ex-spouses), with varying levels of involvement and contact (ranging from living with the person who has a substance use problem to having no current contact), and whose family member may be at varying points in the recovery process (ranging from denial of a substance use problem to maintenance of recovery). The program also had to be flexible enough to be used for family members of different ethnocultural and religious backgrounds and in different settings.

Providing support

Research has long shown that support plays an important role in helping people cope with difficult circumstances. Unfortunately, due to the stigma of substance use and mental health problems, some family members become isolated and do not receive support from others. Treatment offers family members the opportunity to experience professional support and so to reduce their isolation and shame.

Research has demonstrated that family members who take part in group programs such as Al-Anon experience decreased emotional distress and personal problems, due perhaps in part to the support they receive (O’Farrell & Fals-Stewart, 2003). These findings are supported by the feedback from the FAS’s clients, which demonstrated an appreciation of the group’s providing validation and support. The clients also appreciated the fact that they were accountable to the group for the changes that they had agreed to make. We decided to offer our program primarily through a group format not only because it is cost- and resource-effective, but also because it is an effective intervention. A recent review of treatment studies demonstrated that there was no difference in outcomes between group therapy for family members and family therapy (Stanton & Shadish, 1997).

Facilitating skills development

As well as demonstrating the benefit to family members of education and support, research has also shown benefits from skills training through family, couples or family group therapy, including greater decreases in emotional distress, increases in coping skills, and greater positive changes in the behaviour of the person with a substance use problem (O’Farrell & Fals-Stewart, 2003; Rychtarik & McGillicuddy, 2005; Smith & Meyers, 2004; Stanton & Shadish, 1997). Treatment programs that help family members learn new ways of behaving seem to be the most successful in helping both the family member and the person with a substance use problem.

Al-Anon has long emphasized the importance of family members identifying their powerlessness over those who engage in problematic substance use, and accepting that they cannot change another person. However, research has demonstrated that family members do influence one another and can support the recovery of another person (Meyers & Wolfe, 2004). CRAFT has been designated the most effective program for concerned others of adults who have problems with alcohol or other drugs and who are not in treatment (Stanton, 2004). CRAFT is a highly structured cognitive-behavioural treatment approach that helps concerned family members learn new skills in dealing with the person with a substance use problem, with the result of improving their own functioning and that of the person who uses substances (e.g., at least 64 per cent of those identified in the study as “drinkers or drug users” entered treatment) (Miller et al., 1999). Behavioural couples therapy is another intervention that helps clients make behavioural changes in how they respond to each other. It too has demonstrated improvements in the functioning of both spouses (O’Farrell & Fals-Stewart, 2003).

We built on this evidence by incorporating a skills development component into our model.

Providing education

In response to frequent requests from family members for information on a variety of topics, we incorporated an educational component into our model. We believe that when family members are provided education, they are more knowledgeable about their relative’s situation, about substance use and concurrent disorders, and about treatment options; more realistic in their expectations; more firm in setting limits with the person who has a substance use problem; more supportive of the person’s positive gains; and more able to make informed decisions about their own behaviour and responses. A recent study in Sweden demonstrated that spouses of alcoholics exhibited improved coping and decreased distress after receiving one individual information session in which they were educated on coping strategies, alcohol dependence and its effects on the alcoholic partner and the family, and on addiction treatment and social services (Zetterlind et al., 2001).

Pilot stage

Stage 1

After the first draft was completed, the revised program—now called Families CARE—was offered by six therapists at two of CAMH’s facilities. The program comprised three elements.

The first component was a two-hour educational evening for family members that covered substance use and concurrent disorders and their effects on families; the stages of change; the process of recovery and its effect on families; and treatment options for families and for people using substances. Most of the material for this seminar came from modules 2 and 14 of this manual. This educational evening was presented twice, each time by at least two therapists, to 69 family members (24 at one session and 35 at the other). Participants were told at this educational evening that if interested and if they had not already done so, they could contact a therapist and schedule a screening and assessment interview for further services (including individual, couple or group therapy within the Family Addiction Service).

The second component of the program was the screening and assessment interview to determine family members’ eligibility for and interest in participating in the group program.

The third component consisted of eight weeks of group treatment, whose topics were determined by the interest of group members and which are contained within this manual. The group was offered three times, and each was facilitated by two therapists. A total of 31 people participated (25 women and six men), whose relationship to the person with a substance use problem varied.

Stage 2

After the second draft of the program was completed, Families CARE was again offered at CAMH, by seven therapists at two sites over a period of 18 months. This time, 457 people took part in 11 large educational sessions (an average attendance of 42). Of these people, 148 (114 women and 34 men) subsequently took part in a Families CARE group, and 124 completed the program. While each group began with an average of 10 members, the average number of participants per session was seven.

Families CARE was also offered outside of CAMH, in conjunction with Addiction Services for York Region, in order to determine whether our materials could be used successfully in another setting and by someone who was not part of our team, and with a different group of family members. The participants and facilitator of this pilot provided feedback to help us refine the materials.

Feedback

At various points in the development of Families CARE, many professionals and clients provided feedback on the program.

During the first stage of the development process, we asked every family member who attended an educational evening or small group session to fill in our feedback form. We used the information received to help us revise the respective sessions. During the second stage, we asked for feedback from family members who attended an educational evening and then, if they went on to participate in a group, upon completion of the program. Unfortunately we did not obtain written feedback from participants who did not complete the group program.

Educational evening

Family members who attended the educational evenings rated their satisfaction level with the content and presentation on a seven-point scale, with 1 being “not at all satisfied” and 7 being “very satisfied.” The average rating for content was 5.8, and for presentation 5.7. Most participants responded positively about the content, indicating that they found it informative, comprehensive, relevant and practical. Almost as many people mentioned particular topics that they found helpful, such as the stages of change. Other respondents said they found the presenters knowledgeable, caring, understanding and responsive, and skilled in creating an open, relaxed, positive and comfortable atmosphere. A large number expressed their appreciation for the interaction and the social support they experienced during the discussions and the question and answer periods. The participants said they most liked the educational evening because they felt validated, affirmed, supported and encouraged.

When asked what they liked least about the educational evening, family members indicated that it was too short and did not cover enough information, or that the information was not specific to their situation. Many wanted to know more about concurrent disorders, types of drugs and their effects, harm reduction, substance use treatment, recovery and maintenance. Many people also wanted to spend more time learning how they could respond and relate to the person in their lives with a substance use problem. (For those who went on to attend the group sessions, these issues were dealt with in much greater detail in that context.) Some participants said that the group was too big (attendance was as high as 60) and involved too much interaction (this was sometimes defined as other participants asking inappropriate or personal and over-specific questions). Others felt that the format did not allow enough time for questions.

After the educational evening, family members shared their reactions to the evening. The most common responses were that family members had:

• learned new ways of responding to the person with a substance use problem
• developed a greater understanding of addiction, treatment, recovery (including realistic expectations), relapse prevention and the experiences of families and of people with substance use problems
• learned about resources for themselves and for the person with a substance use problem
• started to focus more on their own needs; and to feel less alone and more supported, reassured, and more hopeful.

Group sessions

Group members rated the teaching and discussion component and the homework exercises on a five-point scale, with 1 being “not at all helpful” and 5 being “very helpful.” The average rating for the teaching and discussion was 4.8, and for the homework 4.3. Most participants liked the social aspect of the group, including the social support and their interaction with other group members. Others mentioned the warm and safe environment created, and the skilled facilitation of the leaders. Many expressed appreciation for the content and the educational component, noting how much they had learned and grown, and how much they had appreciated the topics, handouts and homework exercises.

When asked to identify what they had not liked about the program, participants’ comments generally centred on their opinion that the sessions were too short and too few, and that the program did not include a “reunion” session.

Families CARE: Helping Families Cope and Relate Effectively Facilitator’s Manual

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