Social Support

The role of family members and concerned others (CO’s) in engaging substance abusers (SA’s) in treatment has been shown to be significant. Marlowe et al (2001) found that of 415 patients interviewed at admission, family pressure was reported as the main influence in their decision to seek treatment. Simpson and Sells (1990) found 75% of opiate-addicts ranked family as a major reason to enter treatment. It has also been shown that SA’s retain close ties with family members, particularly parents (Heath & Stanton, 2004), which offers an excellent opportunity to engage SA’s in treatment. The best way to get a loved one help for their addiction problems has been the focus of many studies which tout many different approaches.

Possibly the most recognizable approach for concerned other’s to engage SA’s in treatment is the Johnson Institute Intervention. When discussing an “intervention”, this is probably what most people will think of. Developed in the 1960’s by Vernon E. Johnson, this approach involves confronting the Substance Abuser with family and friends, expressing concern and conveying the message that they don’t have to fight this on their own. If the SA refuses to acknowledge the problem, consequences, such as divorce or job loss, are presented.

When used, this approach has been shown to be successful in getting SA’s into treatment. Miller et al (1999) found that 9 out of 12 SA’s confronted using this technique entered treatment. The problem is that only 12 out of 40 subjects in the study agreed to try the intervention, resulting in an overall success rate of 30%.

Similar results were found by Liepman, et al (1989). Six out of seven problem drinkers confronted agreed to enter treatment. But the sample included 25 subjects, 18 of them not attempting the intervention, so the overall success rate dropped into the 30% range. A third study by Barber & Gilbertson (1996) found that none of the 48 CO’s involved were willing to engage in this type of intervention due to its stressful nature.

Community Reinforcement Training (CRT) is an approach designed to take advantage of times when an alcoholic is motivated to get treatment. CO’s are given motivational training and independence from the alcoholic is encouraged. They are taught several reinforcement techniques which include, providing positive consequences for not drinking, scheduling activities to compete with drinking, ignoring the alcoholic when they are drinking alone and allowing the alcoholic to experience the negative consequences of drinking (Kirby et al, 1999). The CO would take advantage of situations where the alcoholic is feeling regret for their actions and exhibits a higher motivation to make changes in their behavior. At these times, the CO would suggest treatment and immediately call the clinic to set up an appointment.

Sisson & Azrin (1986) performed the first study of this approach which included twelve CO’s of alcoholics, seven of which were assigned to the experimental group and five to the control group. Clients in the control or traditional group received the treatment program currently in place at the clinic, they were given educational materials regarding alcoholism, engaged in weekly counseling and encouraged to attend Al-Anon meetings. CO’s in the traditional group were given a list of treatment options should the alcoholic family member request treatment. The alcoholics in both groups were found to be similar in drinking frequency and intoxication before treatment. The reinforcement techniques alone were found to have an effect, reducing drinking by about 50%, before treatment began. Six out of the seven experimental cases initiated treatment compared with none for the traditional program.

In a study comparing CO’s using the CRT approach to a 12-step, self-help strategy, Kirby et al (1999) found Community Reinforcement better at engaging substance abusers in treatment. 32 CO’s were randomly assigned to be in the Community Reinforcement group or the control group which involved counseling sessions in the Al-Anon 12-step model. 64% of the experimental group was able to motivate their family members to enter treatment compared to 17% for the control group. This study also showed that CRT

did a better job of keeping CO’s engaged in treatment.

The Community Reinforcement and Family Training (CRAFT) approach is an enhanced version of the original Community Reinforcement Approach, designed to engage adult drug users in treatment. With CRAFT there are two phases of operation. The first phase has the CO use reinforcement techniques to help reduce the SA’s drug use. When a SA showed proper motivation for treatment, the CO would immediately call the clinic to set up an intake appointment within 48 hours and Phase II would begin. Phase II is designed to engage the SA in treatment by using motivational enhancement techniques, personal assessment results as motivational feedback as well as a core set of procedures based on the Community Reinforcement approach. These include: development of treatment goals, drug refusal training, social skills training and relapse prevention training.

Meyers et al (1999) found the CRAFT approach to be very successful in engaging SA’s in treatment. They also found that the CO reported a benefit whether or not the SA entered treatment. The study started with a sample size of 62 and a time limit of 6 months and a maximum of 12 sessions for both Phase I and Phase II. On average CO’s completed 87% of offered treatment sessions and 74% were able to engage their substance abusing family member in treatment. CO’s also reported an improvement in their emotional and physical well-being.

Miller et al (1999) randomly assigned 130 CO’s to one of three counseling approaches: 1) A 12-step Al-Anon method, 2) A Johnson Institute intervention method or a 3) community reinforcement and family therapy (CRAFT) approach. Each method was designed to include 12 hours of counseling sessions over 6 months for the CO. The CRAFT method proved the most successful as 64% of the SA’s initiated treatment. 30% of the families using the Johnson intervention were successful and only 13% for the Al-Anon approach. The authors found that on average treatment engagement took place after 4 to 6 sessions. Also, parents were more likely to get their problem drinker in treatment then spouses (51% to 32%).

In a recent study the CRAFT approach was enhanced by adding a group aftercare component to the method. Meyers et al (2002) randomly assigned 90 CO’s to either the normal CRAFT approach, The CRAFT approach with group aftercare sessions after completion of the individual sessions or an Al-Anon facilitation therapy approach. The original CRAFT approach had a success rate of 58%, CRAFT + aftercare was at 77% and the Al-Anon approach was successful 29% of the time. In all three studies the CRAFT approach was successful about two-thirds of the time.

Combining some of the elements of Community Reinforcement and the Johnson intervention led to the creation of the Unilateral Family Therapy (UFT) method. Between 11 – 30 counseling sessions are held over 4 – 6 months in which behavioral, coping and education interventions are used with the CO in order for them to become a positive rehabilitation influence on the problem drinker. At some point in the process a programmed intervention takes place to motivate the drinker to enter treatment. Thomas et al (1990) studied a random sample of 50 CO’s who were assigned to either the UFT group, a delayed treatment group or a no-treatment group. The authors report a 6 month engagement rate of 39% for the UFT group, 11% for the delayed treatment group and 15% for the no-treatment group.

Pressures to Change is an intervention that trains CO’s in coping responses which empower the CO as well as provide incentive for the drinker to change. CO’s attend 4-5 weekly sessions in which they are taught to apply incremental amounts of pressure on the problem drinker. Various types of pressure include positively reinforcing non-drinking behaviors, scheduling activities incompatible with drinking or negative reinforcement for drinking. The final step involves a Johnson type intervention if the other levels have not succeeded.

Stanton, M. (2004) reports on three Australian studies that tested the effectiveness of the Pressures to Change model. The first study randomly assigned 23 CO’s of problem drinkers to three treatment approaches, individual therapy, group therapy and a no-therapy/wait list group. The individual group had a successful engagement rate of 38%. The group therapy format had a successful engagement rate of 50% while 0% of those in the wait list group were successful. A second randomized trial of 48 CO’s added an Al-Anon group to the three listed above. The engagement rates were 33% for both the individual and group models and 0% for both the wait-list and Al-Anon groups. The third study compared the Pressures to Change model with a self-help approach plus a no-therapy group. The engagement rates were 25% for Pressures to Change, 20% for the self-help model and 0% for the no treatment group.

In England a Co-Operative Counseling service was created which targeted CO’s as agents to affect change in the problem drinker. The service consisted of two phases. The initial “passive” phase involved listening sympathetically to the CO’s problems and providing them with educational materials on alcohol use which included a non-technical guide to sensible drinking. This was to be passed on to the problem drinker. At the next session the “active” phase began as the problem drinker’s reaction to the material was assessed and an individualized course of action determined. Yates, F.E. (1988) found that after publicity in the local press, the service received 30 calls, which resulted in 4 problem drinkers (or 13%) engaging in treatment.

The Strategic Structural Systems Engagement (SSSE) procedure has shown to be very effective in engaging substance abusing adolescents and their families in treatment. In family therapy the substance abusing adolescent is often seen as the one who needs to change. With SSSE, the therapist focuses attention on the whole family. Although one member may be manifesting the symptom or problem, treatment must focus on the family interactions that allow the symptom to persist. With this approach the therapist “joins” with the family in a way that does not threaten it’s structure and attempts to change only those interactions that prevent family members from getting into treatment (Szapocznik et al, 1988).

In a study of 193 Hispanic drug-abusing adolescents, the goal was to engage the adolescents and all adult caretakers living in the same household in an intake appointment within 3 weeks of initial contact (Szapocznik et al, 1988). After 2.5 contacts, which were defined as phone calls, home visits and office sessions, 93% of those in the SSSE group had initiated treatment. An engagement as usual control group had a success rate of 42%. A later study with a more stringent definition of success (intake appointment plus a first treatment session) resulted in a success rate of 81% for SSSE and 57% for the engagement as usual group (Santisteban et al, 1996).

The Intensive Parent and Youth Attendance Intervention is a method to try and get adolescent drug abusers into treatment as quickly as possible. There are 2 methods to this intervention. The first, called the Parent-Focused approach, starts when the parent or guardian of a troubled youth, calls an intake staff person. The staff person reads a standardized program overview promoting the advantages of treatment. An intake appointment is then scheduled to take place within 2 – 7 days. The second method is called the Intensive Parent and Youth Attendance Intervention which adds motivational telephone reminder calls to both the parent and the youth. The phone calls provide information on the treatment and occur two to three days before the scheduled appointment.

The two approaches plus a control group were examined in a study with 39 adolescents (Donahue et al, 1998). The Intensive Patent and Youth Attendance intervention successfully engaged 89% of the adolescents. The Parent-focused intervention was successful 60% of the time while the control group using the clinics’ typical appointment procedure engaged 45% of the youth.

A Relational Intervention Sequence for Engagement (ARISE) is a rapid response intervention that attempts to involve the family and social network of the SA. The focus from the start is to get the CO believing that they can’t do this alone and encourage them to get as many family and friends involved in the process. A meeting is scheduled with the family and friends to discuss how best to get the SA into treatment. The SA is also invited to that initial meeting with the intention made clear. Secrecy is discouraged in this process. If the SA refuses to enter treatment the program can advance to a Johnson-like intervention where consequences are presented to the SA. Rapid intake is a key component of this method in order to increase the likelihood that the appointment will be kept.

Landau et al (2001) performed an outcome study of the ARISE method and found that out of 110 CO’s calling in to two different treatment centers 83% of the cases became engaged. 76% of those entering treatment did so within 14 days.

Recognizing the ability of family members and friends to influence and change substance abusers behavior will allow treatment facilities to use these resources in their attempts to increase access to their services. By engaging the family and friends of substance abusers in treatment, clinics gain a powerful advantage in their attempts to increase access to services. Often the first contact for help comes from concerned others and being able to quickly engage them in the treatment process will greatly increase the chances of the substance abuser entering treatment.