Kim Halford, W. and Frost, Aaron D.J. 2021. Depression Anxiety Stress Scale-10: A Brief Measure for Routine Psychotherapy Outcome and Progress Assessment. Behaviour Change, Vol. 38, Issue. 4, p. 221.
Ibrahim, Maliha Palit, Manjushree and Mathews, Rhea 2022. Family Therapy - Recent Advances in Clinical and Crisis Settings [Working Title].
Ayub, Nadia Iqbal, Shahid Halford, W. Kim and van de Vijver, Fons 2022. Couples relationship standards and satisfaction in Pakistani couples. Journal of Marital and Family Therapy,
As with the RCTs, most of the included observational studies were of mixed quality. Two common study design features within this group are the non-randomized, uncontrolled nature of the nine included pre-post studies,7,9,14,15,19–25 and the non-randomized nature of the one included cohort study.26 The lack of randomization increases the potential for selection bias, while the uncontrolled nature of the pre-post studies makes it impossible to distinguish intervention effects from other effects such as regression to the mean, natural progression, or social desirability. As with the RCTs, validated outcome measures were used across all observational studies, but due to the subjective nature of these self-report instruments, especially within a non-blinded, non-randomized, uncontrolled design, the potential for measurement error is increased. Finally, due to the nature of the intervention, neither blinding of patients nor therapists was possible. The lack of blinding, in addition to the use of self-report measures, increases the potential for bias in outcome assessment, in particular since participants are aware they received the intervention and the desired direction of effect.
As with the RCTs, most observational studies included an explicit description of study objectives, hypotheses, eligibility criteria, outcomes, and interventions, allowing for a comprehensive appraisal of study quality. Further, an explicit description of the therapist[s] and their related training across all studies provides assurance the intervention was delivered consistently and as intended.
None of the included studies, however, provided a power calculation nor justification for the number of included couples, although three studies were identified as pilot studies,7,9,19,20 where hypothesis testing was not the main goal. Despite not providing justification for the sample size, four of the included observational studies included an analysis of clinical significance of the primary outcome, suggesting these studies were adequately powered to detect a meaningful difference.14,15,20,23,24 As with the RCT reports, none of the observational studies included information about adverse event tracking raising the potential that these important outcomes were not tracked, as opposed to not reported. External validity is further limited in five of the pre-post studies due to poor reporting of sampling procedures, in particular whether people who agreed to participate were different in any meaningful way from those who did not participate.7,9,19–21,24
Intervention compliance was adequate within seven of the ten included observational studies,7,9,19,20,22,23,25,26 but low within two.14,15,24 Compliance was not reported within one study report.21 For each of the observational studies, non-compliant patients were excluded from the analysis, which raises the likelihood of overestimating treatment results especially for those studies with low compliance.14,15,24 In one pre-post study compliance was low within both study sites, but compliance rates differed significantly between study sites.14,15 In addition, for this particular study, the publication notes considerable differences in participant characteristics across study sites in terms of ethnicity, religion, education and income, in addition to differences in intervention delivery in terms of focus, scope, and treatment duration.14,15 Given results for this study were combined across study sites, these between site differences increase the potential for bias in outcome measurement since measurement effects will be impacted differently by both compliance and the intervention across included participants.
Address for correspondence: L.N.Suman, Professor and Head, Department of Clinical Psychology, NIMHANS, Bengaluru, Karnataka, India. E-mail: ni.cin.rak.snahmin@senele
Copyright : © 2018 Indian Journal of Psychiatry
This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
Abstract
Substance abuse is a family disease that adversely impacts both the user and the user's family. The family can act as a risk factor for the development of substance abuse among children and adults. The family can also be involved in therapy to either help the recovery process or prevent substance abuse. Marital and family therapy have been found to be effective in reducing the severity of substance use, lowering marital and family conflict, improving family communication and cohesion as well as effective parenting practices. Behavioural Couples Therapy has been found to have good empirical support for bringing about the desired changes in both substance abuse and marital relationship. While targeting entire families, the most common evidenced based family interventions are Brief Strategic Family Therapy, Multidimensional Family Therapy, Family Behaviour Therapy, Functional Family Therapy and Community Reinforcement Programme. Marital and family therapy have to be sensitive to gender and culture. Effective use of marital and family therapy requires adequate training to equip practitioners in adequately treating not only substance use disorders and family pathology, but also in treating co-morbid mental health conditions.
Keywords: Substance abuse, Marital therapy, Family therapy, Adolescence, Prevention
INTRODUCTION
The focus of family therapy treatment is to intervene in complex relational patterns and to alter them in ways that bring about productive change for the entire family. Family therapy rests on the systems perspective, which proposes that changes in one part of the system can and do produce changes in other parts of the system, and these changes can contribute to solutions. Family therapy in substance abuse treatment has two main purposes. First, it seeks to use the family's strengths and resources to help find or develop ways to live without substances of abuse. Second, it reduces the impact of chemical dependency on both the patient and the family. In family therapy, the focus of treatment is the family, and/or the individual within the context of the family system. The person abusing substances is regarded as a subsystem within the family unit—the person whose symptoms have severe repercussions throughout the family system. The familial relationships within this subsystem are the points of therapeutic interest and intervention1.
Family is a key resource in the care of patients in India as its culture of inter-dependence gives the family a pre-eminent status. Psychoactive substance abuse and dependence has a significant deleterious impact on the family of the substance user. This impact can then lead to a chain of events which can not only spiral out of control but also spiral downward. In a study carried out in India2, family burden was found to be moderate to severe in families with a substance dependent person. The burden was characterized by disruption of family interactions, disruption of family routine, disruption of family leisure and financial burden. According to Kumfer3, since substance abuse is a ‘family disease’ of lifestyle, including both genetic and family environmental causes, effective family strengthening prevention programmes should be included in all comprehensive substance abuse prevention activities.
THEORETICAL BACKGROUND
Studies carried out in the Indian setting have indicated that alcohol dependence in men is linked to marital dissatisfaction4 and domestic violence5, psychological distress among their sons6 and poor parenting practices by the alcohol dependents7. Further, alcohol dependence in men has been implicated in family disintegration8, forcing spouses of alcohol dependents with poor support systems to seek refuge in shelter homes9 and contributing to adverse childhood experiences in the lives of their children10. In addition, family substance abuse is a risk factor for children to develop substance use disorders through interplay of genetic and environmental factors. For instance, parental substance use has been associated with positive expectancies from the substances among their children11 This familial risk factor has been implicated in pathways to substance abuse among women as well12.
Apart from the harm caused to the spouses and children due to substance abuse among men, substance abuse among adolescents and young adults has been associated with parental distress and stress13. It must be noted that the family can play an important role in preventing substance use among adolescents through maintaining close ties, providing care and nurturance and ensuring adequate monitoring and supervision. The family can also ensure a substance free lifestyle by conforming to social norms and practicing religiosity/spirituality14. It has been found that adolescents also perceive a need for parental guidance and family support in their journey of recovery from substance abuse15.
It is evident that the family can be a risk factor as well as a protective factor. Additionally, the family can facilitate recovery or impede recovery. The astute clinician has to examine various strands of family functioning to determine what aspects have to be strengthened, altered or reduced in order to improve the effectiveness of the approach. These clinical decisions will be informed by the unique features in a given case, making the therapy individually tailored. Thus, empirical literature indicates that clinicians providing interventions for substance dependence should give as much attention to the family as they would give to the patient.
CLINICAL APPLICATIONS
Couple Therapy
Couples therapy has been found to be an efficacious treatment for persons with substance use problems. Therapy programmes which have included spouses have been found to be effective in motivating patients to enter and continue treatment. They have also been associated with better outcomes in treatment such as lower substance use, longer periods of abstinence and better marital functioning. The theoretical framework underlying couples therapy is an understanding of substance use and marital discord as being cyclic. Problems in the marital relationship, poor communication and poor problem solving may precede harmful use of substances, and dysfunctional relationships can maintain and facilitate the substance use. Marital and family conflicts also have the propensity to facilitate relapse16. In a critique of 41 different treatments for alcohol problems, Behavioural Couples Therapy [BCT] was found to be the only type of family intervention and one of 16 therapies to have adequate empirical support for effectiveness17. Hence, the National Institute of Clinical Excellence Guidelines recommends BCT for individuals with harmful drinking and alcohol dependence18.
In BCT, the patient and spouse are typically seen together in 12-20 weekly outpatient sessions over a 3-6 month period. BCT can be an adjunct to other psychotherapeutic interventions or the mainstay in therapy. Indications for BCT are: availability of both partners for sessions; couples that are married or cohabiting at least for the last one year; one member with substance use problems. Contraindications for BCT are: couple ordered by court to have no contact with each other; gross cognitive impairment or psychosis; severe physical aggression; when both spouses have substance use problems. The intervention is aimed at two goals – substance use recovery and enhanced relationship functioning. Substance use recovery is addressed first with the therapist understanding the patterns of substance use and interactions in the marital dyad19. This is indicated in Figure 1:
Open in a separate window
Figure 1
Cycle of treatment components of BCT
Relationship focused interventions are introduced once the patient has maintained abstinence and the couple is regular to sessions. The major goals of this part of the treatment are to enhance positive feelings, communication skills and problem solving. Communication skills include listening skills, expressing emotions directly and negotiation skill
Family Therapy
The focus of substance abuse treatment worldwide is shifting from corrective to a preventive approach. This is due to the fact that the age of developing substance related problems is reducing and impacting the youth. Effective treatment for adolescents is suggested to be one that brings about change in various domains of a young individual's life and context. This necessitates family therapy and combined family and community based interventions for adolescent substance abuse. The therapist and the family should be equal participants in the therapeutic process. Including adolescents' parents into any treatment programme increases the likelihood of treatment adherence and compliance. As a result, family involvement and post treatment support facilitate successful outcomes in treatment of adolescent substance abuse20.
The term ‘Family Based Interventions' is used to describe a collection of intervention models that focus on family communication, cohesion, conflict and parenting practices. The most common evidenced based family interventions are Brief Strategic Family Therapy, Multidimensional Family Therapy, Family Behaviour Therapy, Functional Family Therapy and Community Reinforcement Programme. The goals of these interventions are to bring about systemic changes, skills building, enhancing positive family and social activities, improving communication, problem solving and making non-substance use rewarding21. These interventions have shown better outcomes in terms of reduction in substance use, improved family relations, better work outcomes, adherence to treatment, treatment retention and long- term maintenance of gains22.
Gender and culture are also significant in planning or developing a therapy that aims to modify the immediate social and cultural environment of the adolescent. For instance, abuse, abandonment and depression are key issues that must be addressed for girls with substance use disorders in treatment. Trauma models of substance abuse among girls and women indicate the need to make their family environments safer and healthier. Such gender sensitivity and targeting of delicate issues are very therapeutic and are key factors in reducing self-harm behaviours among girls and young women. Family interventions also effectively reduce intimate partner violence and thereby reduce child exposure to domestic violence [CEDV]. The greater stigma attached to substance abuse among girls and women can also be addressed in family therapy in order to reduce feelings of shame and guilt23. In addition, the professional treating a patient and family cannot overlook the cultural background that the patient's family comes from. Being culturally sensitive necessarily does not mean that the therapist must belong to the culture, but rather that they have developed sensitivity to the culture by gaining knowledge, observing and paying attention to various behaviours and dynamics and is ready to learn from the patients and their families. The therapist should understand how cultural differences influence substance abuse, health beliefs, help-seeking behaviour and perceptions of behavioural health services24.
Table 1
Components of Relationship Promises
Open in a separate window
Table 2
Increasing Positive Exchanges
Open in a separate window
The family also plays an important role in prevention of substance use and evidence-based interventions for preventing substance use disorders include programs such as ‘Family Matters’, ‘Creating Lasting Family Connections' and ‘Brief Strategic Family Therapy’. ‘Family Matters' is a universal prevention programme that enables families to identity and address family characteristics, behaviours, and attitudes that can influence adolescent substance use. These include levels of adult supervision and support; family rule-setting and communication; family time spent together; parental monitoring; family/adult substance use; the availability of substances; and social attitudes about substance use in the media and among peers. ‘Creating Lasting Family Connections' is a selective programme designed for youth and families in high-risk environments that focus on substance use issues, personal and family responsibilities, and communication and refusal skills. ‘Brief Strategic Family Therapy’ is an indicated programme designed for families in which children and adolescents exhibit early substance use, rebelliousness, and/or delinquency. This approach strives to increase and reinforce competent family interactions and behaviours through shifting interpersonal boundaries as needed, building conflict resolution skills, and providing parental coaching25.
Family engagement can range over various modalities, such as telephonic conversations, video sessions, counselling groups, family sessions where the adolescent-family interaction is observed as well as separate sessions with parents, addressing focused upon issues to enhance treatment outcome. Therapy motivations of the parents and family therapy with single parent families are issues that must be clinically assessed and addressed not only before initiating therapeutic contact, but also during the intervention26. Further, parents' own substance use difficulties, quality of marital relationship and mental health must be assessed and addressed if required to reduce dysfunction in the family and improve family atmosphere27. It is advisable to see the family members separately in individual sessions in order to get pertinent information. Some disclosures may be made only to the therapist and the other family members may be unaware of the disclosed information. It is important for the therapist to maintain privacy and confidentiality regarding such ‘family secrets' within the boundaries of ethical guidelines and legal directives. It is also important for the therapist to be objective and not to take sides of any one family member or a dyad.
Therapist's training and experience is mandatory before trying out any intervention. Therapists must be experienced in family therapy skills, and should have had training in individual therapy. Ideally, the therapist must be knowledgeable about family therapy practices as well as substance abuse treatment practices. Family therapists who wish to treat substance abuse must get themselves informed about basic substance related issues as well as substance abuse treatment processes. This may include screening and assessment of substance use, motivational enhancement techniques, relapse prevention, as well as training in specific models of therapy, for e.g. Cognitive Behavioural Therapy for substance abuse or Dialectical Behaviour Therapy for co-morbid substance dependence and emotionally unstable personality. Recently28, it has been recommended that integrated interventions be used for co-occurring substance use disorders and other psychiatric disorders rather than treating only substance abuse or treating only the co-occurring disorder. This approach will necessitate the availability of experienced clinicians and therapists and training will be required to equip practitioners in adequately treating the conditions.
Summary and Future Directions
Substance abuse has a tremendous impact on not only the user but also on the user's family. The family can be a risk factor for substance abuse or it can act as an important resource for recovery from substance abuse. Marital and family therapy for substance abuse have been found to be efficacious for men, women and adolescents. Family interventions have also been successfully used to prevent substance misuse. Considering the sheer number of individuals with substance abuse problems in India, effective treatments such as marital and family therapy should be regularly offered to patients and their family members whenever indicated. This would require tremendous and sustained efforts to train a large number of mental health professionals in these therapy modalities. Apart from ensuring that quality care is provided, it is also important to make the therapies accessible and affordable. In order to maintain contact with the therapist, feasible and affordable technology driven tools such as mobile messaging and apps, and therapy sessions using the internet can be employed. Dedicated programmes that involve the family and community are also required to prevent substance abuse among children and adolescents. These psychosocial interventions are vital for a country like India with its emphasis on family oriented living.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
SELECT REFERENCES
1. Substance Abuse and Mental Health Services Administration [SAMHSA] Improving Cultural Competence. Treatment Improvement Protocol [TIP] Series No. 39. HHS Publication No. [SMA] 05-4006.
Which type of therapy is likely to primarily focus on the sentiments partners experience as they seek to fulfill their attachment needs?
What type of couples therapy strives to improve relationships by increasing the partners attachment security?
Which type of therapy is likely to focus on instilling reasonable expectations and relationship beliefs?
Which type of therapy is likely to focus on helping to train spouses to treat each other in a manner?