CTN Webinar: Family Involvement in Substance Use Disorder and Mental Health Treatment and Research.

I'm Dennis daily from Pittsburgh the director of the appalachian tri-state node as clinical trials Network and I've been involved in treatment of addiction and co-occurring for decades and I've done a lot of clinical work with families as well as individuals so it's a pleasure to be here John Hamilton I've been involved with the clinical trials network from from the beginning and I'm involved in the New England consortium and had been involved as chairing the dissemination committee at one point presently on the steering committee and have involved in had been involved in two of the blending products early on the mia step and the Pammy and has really enjoyed my relationship with that I've built with researchers and other clinicians around the country developing evidence-based practices as a result okay well it's a pleasure to work with John I think John is an incredible professional in terms of not only running a large continuum of services but like me and a lot of others he still likes to see patients and families which I really think is a great idea now this is called family involvement in substance use disorder mental health treatment and research but the main focus will be more related to substance use disorders and what we want to do is discuss the impact of these disorders on the family the family units are systems as well as individual members including children we want to talk about strategies and challenges for patients to address family issues when they're in treatment for the substitutes disorder were involved in recovery will review interventions to help families and that at the end we'll have a discussion of what you think what we all think might be some interesting ideas for research for families some potential research questions or areas so the first objective will be to look at the impact of disorders on the family and marital systems and individual members including children and I want to point out that all families are not affected in the same way the the actual effects are mediated by a number of and they would these would include specific things such as the severity of the substance use disorder the behavior of the affected family member so for example of someone to violent or suicidal that will have a different impact on the family than this or not the presence of comorbidity it could be psychiatric comorbidity it could be a serious medical problem could be social comorbidity the support that the family members receive within and outside the family and also the psychological coping strategies or resilience ease of family members and you know as many of you know if you've been around for a long time you know we've thrown around terms like codependence and we'd put these negative labels on families I think we have to be careful about that because there's a lot of folks who have been affected adversely but they have great resiliency skills so if you look at these disorders and no different than other disorders behavioral health disorders they run in families in fact there are many many different studies of children that show that if a biological parent has an alcohol or drug problem they're an increased risk themselves and that's similar with other disorders we have an example here of mood disorders and twins but you could also say this with bipolar illness schizophrenia and some other psychiatric disorders they do have a family component there is a predisposition based on families now how having said that that does not mean everyone in the family will get the disorder in fact i always find this intriguing because in my own family i'm one of six kids and my father was a chronic alcoholic with psychiatric issues as well and there were four out of six kids with addiction in my family and on his side of the family there were very high rates of addiction whereas on my mother's side there was no addiction at all so it's always intriguing to me how families are affected differently now if you look at some of the specific effects and they would include I think the most common based on the clinical literature the the the research surveys we've done surveys others others have done is the emotional distress and it can affect the family atmosphere what it feels to be in a specific family you people may feel angry they may feel resentful they made Hostel anxiety and warrior in common we work with a group of parents under the past year and some of the most common worries they expressed and these were mainly parents of opiate addicted young adults or teenagers and their biggest fears were overdose death or an overdose or relapse or being incarcerated or just sort of losing their direction in life depression and grief or common and you have grief because we have people who died as a result of their addiction which has a huge impact on parents or people left behind guilt shame and embarrassment the helplessness hopelessness sometimes as part of a clinical depression sometimes not chronic stress so these are part of the emotional effects on the family but you have other effects as well I wanted to mention one is family instability you have increased rates of separation and divorce increase race of children and youth involvement taking away kids then the last one I want to mention which I've heard a lot more about in recent months is the financial impact and I gave a talk to a family group last Wednesday night the mother came up afterwards and I felt bad because she has a young 22 year old daughter that's been in multiple treatments you know we know this is a relapsing disease for many and I didn't even figure this out financially but I surmise from which he told me that they spent a fortune on treatment episodes for her daughter and not only did they spend a fortune on the treatment episode but they did it at the price of not being able to take care of themselves so the financial aspects are important as well now if you look at children addicted moms whether you're talking about opioids are you talking about alcohol or other drugs that has prenatal and postnatal effects which are adverse is a whole literature in this we had mentioned kids are a high rate risk for substance use disorders they're also high rates for depression anxiety oppositional disorders which show in problems getting along with other kids or problems with the legal system or problems at school medical and academic problems and they're more likely to be impulsive inattentive or irritable and this may be because their executive functions of the brain are affected where they can't reason as well as other kids and I do think if I look at the field having been in the field for decades I think that one of the trends recently has that we have less focus on the family in text books research educational programs and conferences and workshops and clinical services so one of the messages I want to give people is to take a look at what do you offer for families if anything should you do anything differently because i really think that field is losing its way and i'm very bothered by that and so there's a group here that have studied kids they have a big study kids for close to 30 years who've had fathers with a drug addiction and they compare them to community controls and they found these kids had lower IQ scores and they don't do as well as in school as well and here's just one quote from one young kid my dad's a dixon mess with me in lots of ways got in trouble with the law almost dropped out of school and you know that if kids don't finish school they're less likely to be successful in terms of work or career economic survival no sorts of things as well so you have the academic effects you also have the emotional distress anxiety depression on kids how you have if you go to psychiatric hospitals you'll see increase rates of kids admitted for mood disorders that are children of parents who have a substance use disorder and I think to I don't think I don't think any kind of data can convey what it's like for a child so if you look at some of the quotes for example and these are for these are from kids we've interviewed in the past it made me sad and afraid I worried something bad would happen to dad I felt so alone and depressed so if you think about this from the child's point of view you can understand how difficult it is but you have to keep in mind too that children often do not express these directly they express it more in their effect or in their behaviors or in their academic achievement or underachievement you also have higher rates of abuse of neglect of hampshire substance abuse was involved in the majority of abuse in the cases so you can imagine what it's like for this little boy and I've talked to many people over the years who have felt neglected in our culture there's so much focus on physical abuse we often minimize the impact of emotional abuse which can be caused by not having access to one's mother and one's father and again addiction will take this away so that's just a brief review that some of the adverse effects are certainly or other ones as well but those are some of the most common ones and John will take it over and talk about some client barriers and some strategies related to treatment and recovery Thank You Dennis yes I mean it is wonderful as family therapy as an intervention there are still many challenges regarding clients involvement family involvement and even staff that become obstacles but can be worked with to introduce it into your system of care and so my objective that I'm going to speak on briefly is the challenges and strategies for patients and clients to address family issues and treatment and recovery and what one of the first barriers I think Dennis had touched on it earlier you know the issues around language too for the clients and the families is I believe the language of recovery is more empowering strength-based and resiliency based in general except when it comes to speaking about families with such pathological terms as codependent on abling and dysfunctional families I think it just adds to this kind of shame based interventions that had historically been introduced before the evidence was there as treatment models of pointing the fingers at families who already feel like it's their fault or there or the individuals in their loved ones and it became its own obstacle so from a client's perspective of barriers they're their own sense of shame and guilt over the past is a clear obstacle they also would like to think it's their problem and they take full responsibility for it so they don't want to pull their families in again this is misguided because they're missing point that families need and deserve support and healing as well there are other commitments have become a challenge particularly for women we find that issues around transportation and childcare become real obstacles of bringing families in and there's sometimes there's just a sense of ambivalence they in their recovery process and there's something that they don't want you to know about as the the clinician or the treating system that their family may expose and like anybody including myself who likes being told what to do so that becomes a big issue so i think the overarching piece that I've seen also with clients is that there are oftentimes a vivillon when they walk into my system a care on their recovery in the stages of change model they may be pre contemplative and contemplative whereas oftentimes family members are at those stage of readiness a stage a change of towards wanting to do whatever it takes to help their loved ones but because the client is in a position where they're still on the fence of whether or not they are not quite sure if they are going to be able to have sustained their recovery I've had convict candid conversations with with with these clients that have told me they don't want to bring their family and only to disappoint them again if they go out and they relapse so next slide now so there are many evidence-based practices that we already have infused in most of our treatment models both an individual groups matrix model relapse prevention and obviously marital and family therapy touches upon family issues and it's infused in much of the programming but oftentimes isn't specifically separated out for a family program so I just wanted to note that that people should get credit for the work they do like the internal family systems work and the CBT work that includes family and relapse prevention that would oftentimes include the relapse prevention and recovery management of significant other and family involvement which becomes so key and having a person go back into the community and we redefine relationships in a manner that promotes recovery for all we need to understand the impact of the substance abuse disorder on the family incur families to become educated that becomes a key piece first do no harm is one of the philosophies we have in our agency whereas if family members are not involved in being educated about what treatment and recovery is and isn't they could inadvertently sabotage treatment we find this particularly present in their methadone programs and medication assisted treatment where the fat where the individual the client or patient would come in saying they want to come off methadone and as we continue the conversation with them we find it's their family members that are pressing them to come off because they don't understand that it's a medication for their treatment and they were uncomfortable with them being on that medication so again this also speaks to the fact that you don't need family therapists to do this family work oftentimes exactly what a family member needs is just a skilled clinician a counselor that can educate on what recovery is on what buprenorphine is and what methadone is and giving them the facts so they understand what recovery is and how to support it with their loved one there is also involvement with family in family sessions to let them know that that their recovery is independent of their loved one and to try to get them involved in having their own support network so they don't feel alone and then obviously in an instep philosophy family involvement covered with making amends and it oftentimes is included as part of the making amends process and sometimes we find that when we bring family members in they too may need assessment and diagnosis and treatment for their own substance abuse disorder reception seuss disorder a psychiatric disorder that they could also use some help with so it's an opportunity to get everybody in the family help so now I'm going to review the barriers and family interventions on the clinical trials meta-analysis literature sam says national registry for evidence-based practices so we're going to touch upon what some of these barriers are so have you as i said earlier boy if this family therapy is so great why is it you so infrequently one of the first barriers I believe that I've noticed in the system or one thing that I can that I've noticed in the treatment field of addiction the bifurcated system it's really set up in a siloed manner where private for-profit programs often times are most often seeing family involvement as an expectation and treatment and the nonprofit world in my experience has not had the same level of family involvement as the for-profit world for the family involvement in in the commercial clients in the for-profit world there's a practical consideration where families come in and oftentimes will support the cost of treatment through their own commercial insurance and for sometimes in out-of-pocket copay that because their loved ones in the throes of addiction they do not have the resources to be able to cover so I think this is an important distinction that I've seen then in some ways has split the field for the more universal and standardized involvement of family in in the entire field so from the family's perspective some of the barriers is they already feel like it's their fault and sadly enough some families have gotten some bad family therapy in the past in treatment programs years ago where they had the finger pointed to them and said it was their fault and they were enabling or they were codependent and they were dysfunctional and it just had them feel even more shamed and guilty and not want to come involved and get yelled at because they already feel like it's their fault and also there's the sense that family members sometimes a tribute to much of a personalizing or what happens with not recognizing that relapse is part of recovery in this chronic disease so they actually start to take it personally that how could they do this to me I think the semantics is that oftentimes family members trust their loved ones and don't have faith in them and it sounds like a semantic issue but we spend a lot of time kind of having the sense that when a family member says I trusted that you were going to come out of detox or come out of residential treatment and stay in recovery they made it about them and it wasn't unreason ton realistic expectation versus having faith that their loved one their client their patient it is doing the best they can with the resources and choices they see as available and sometimes relapse is part of recovery and it's it's difficult for them not to take it personally but it's also important for them to recognize that if their loved one does relapse their recovery process is independent of that and they could still get the help and support that they need to be more reasonable about what healthy support is for them and their loved one so they're unable to see how they can help the family member so they just get frustrated and clients sometimes advise them not to go to sessions because again so you know they don't want the accountability at times I've seen we had tracked our clients in one of our methadone programs and pupae norfin programs that are young adults were coming out at higher rates and we thought it might have been co-occurring disorders but when we actually dug a little deeper we found out that the individuals that were under 23 or 24 would come in and not sign releases for their families didn't get family involved and they kind of they came in sometimes just managing their addiction and not their recovery their recovery in an anonymous way and left in an anonymous way without their family ever knowing that they want for help so now we have an expectation in our treatment programs that anyone under 24 there's an expectation of family or significant other to be involved in their treatment and we've had a much greater significant retention rates with those individuals because now they're committed to recognize there's a higher level of accountability with their family and that their family oftentimes give them the support is necessary to stay sustained in treatment now from the staff perspective again some of the confusion is family staff members that I've work with feel that if they're not a licensed family therapist they're working outside of their purview of expertise this is not the case as I indicated earlier that many cases families just need an education of addiction in general and what walking them through what recovery is like what the schedule is like what their their loved one experiences and being able to answer questions about addiction and recovery becomes sometimes most paramount and families being able to sign on and support the recovery process other staff sometimes it tips their hand in their philosophy of care that you find that some of the staff that are maybe more confrontive than others which we know in evidence-based practices and our friend Bill Miller will always say confrontation doesn't work that I've had family of that counselors tell me well I can't tell the family members what to do I can't confront them and of course kind of tips the hand that it's time for more supervision and support because they probably shouldn't be telling their care clients what to do and confronting them as well but that does become an issue it causes too much stress and affects relapses another myth in fact most of the research as Dennis shared earlier we'll share again is compelling arguments that family involvement will improve outcomes for all and this frustration over the inability to get members and treatment sometimes staff are not comfortable trying to engage family members and sometimes it's just a practical consideration that they live outside of the state but my experience is when you make it an expectation of treatment and tie it into incentives whether it's outpatient methadone residential for take home bottles for for completing treatment earlier for visits for weekend passes you'll find you'll get family members to come in and of course we look at family as anyone who is committed to the person's recovery so it's any loved one it could be an extended definition of family including sponsor employee somebody from the faith community anybody who's committed in that person's recovery we will welcome and support and the other issue to with with staff is the issues around countertransference it says the expression says it's hard to take somebody beyond where you've gone yourself and for some staff members that I've worked with they've done great work maybe in their own recovery or in their own life in therapy but they haven't touched upon their own family of origin issues so it pushes a button for them sometimes to work with families if they haven't done that work themselves they need to keep that out of the of the work that they're doing with individuals and again it's the the need for supervision to make sure that their issues are not interfering with their ability to treat family members with dignity and respect family interventions for psychiatric association fees disorder you can see the enwrap which is the national registry of evidence-based programs and practices there's compelling research that shows and getting increased engagement retention rates for the individual reducing family burden and improved improvement among individual members it's just compelling and significant the sciences there to show it but we just not we just have not had the widespread adoption of family involvement in the addiction treatment model so what is family therapy family therapy can be seen as a collection approaches that share that share the belief and effectiveness of family involvement the family systems theory is the change in any part of the system may lead to change in other parts of the system family therapy for in substance abusers have to made purposes to use family strength and resources to find ways to live without substances and familiar eight the impact of substance abuse disorders unidentified patient and family going to the family strengths of point again mentioning what Dennis said earlier about pathology and language like codependency there had been an exercise years ago of doing Gina grams to show oftentimes the widespread intergenerational patterns of addiction or substance use disorder a mental illness what we found is that is not as helpful as actually identifying with a genogram a strength-based resiliency based genogram to ask the family when doing a genogram of looking at different generations of who else had similar struggles and what did they do that was most helpful now you have a hopeful strength-based culturally competent intervention that's based on what works for that family is a great place to start okay models of family therapy and substance abuse treatment again we have different models that are out there the family disease model which again I unfortunately includes some pathological languages such as dysfunction but the idea of it being a transgenerational process is helpful and hopeful but some of the language needs to be changed family systems is generally the overarching concept and most family models some cbt models cognitive behavioral therapy models in the last four bullets the multidimensional functional family therapy multi-systemic and brief strategic family therapy are all models that are based on working with young people and intervening with young people and again most much of this model today is happening with young adults in adolescent programs and young adult developmental models however in my experience with working with older adults and adults there is not that widespread adoption of family therapy as a strategy towards working with adults and addiction and co-occurring treatments so the goals of family therapy is to help family become aware of their own needs to provide genuine and during healing for family members really offering them hope and faith shifting power to parental figures empowering them not in a tyrannical manner but with rational authority by way of their wisdom and expertise improving communication in the family helping family makes changes to affect substance abuse the substance abusing member help keep the substance music member from moving to the next generation which is what I mentioned earlier that transgenerational pattern and helping families solve problems were affected by these disorders even if they don't have a member with with a disorder and I'm the example best example I can give as I have a colleague who was six year old daughter and 61 year-old mother were killed in front of her on the sidewalk when a drunk driver came up on the sidewalk and then I have a work with that athletes college athletes and I wanted to point out that even one episode of drunkenness bad things can happen you don't even have to have an addiction or alcoholism and I think of a young man who was well-liked good student good athlete got drunk one night decided he wanted to ring the church bell two o'clock in the morning climbed up into the crawl space in the church he was crawling across to get to the bell to ring and one of his teammates was behind him and his teammates said hey Billy Billy Billy let's stop let's go back and Billy said no and then three seconds later he saw a white in her thud the young football player fell through the insulation hit his head on a church pew and then bag within two days and then the reason I bring that is it if you look at if you look what's going on our culture currently this is all throughout the news you're just seeing all these episodes of drunkenness these young people getting into severe trouble whether it's a automobile accident or you had the two athletes from Vanderbilt who recently were convicted of rape and sent to prison for decades because of getting drunk and having sex with a woman who wasn't interested so these disorders affect everyone not just the families with it with a disorder so you have a number of family models and one of the big big issues is how do you get people in treatment because majority don't get treatment only about ten to fifteen percent get treatment and most get treatment because of pressure or influence from the legal system employers have excuse me families or medical professionals who make referrals and the craft model is designed to get the member with the problem into treatment and they have high success rates as you can see with some of the data there it also aims to get the member to stop or reduce substance use and there's great effectiveness in terms of reducing or stopping alcorn drug use but very importantly very importantly in the last point is to help families improve or enrich their own legs too often in treatment everything focuses on the patient with a substance use disorder the mental health disorder and not on what is it like for the family how can we help them how can we reduce their burden their emotional burn their psychological burden and I think programs like this can make a big difference with families if you look at family engagement interventions there's some other ones the arise model the trapped I'd mention brief strategic family therapy they all show much higher rates of engagement in treatment then you have from treatment as usual and now I haven't seen this recently but there was only one small study that Johnson Institute intervention model and it did show much efficacy and that's the model that was used quite often from around the country but you do have models of an engagement that do make a difference now there are also a lot of studies of adolescents these particular this particular group here is more the adolescent therapies in fact the family treatments the treatment of choice if the adolescent has a substance use disorder and what they find is superiors alts of family involvement compared to other approaches now that doesn't mean that other approaches don't work they do family approaches work better and so you have better outcomes with alcohol and drug use better outcomes with school grades and pro-social behaviors and also better outcomes with families families function better they feel better they get along better which is very important as well if you look at family therapies from the point of view of the member with the substance use disorder they're more likely to stay in treatment and as we know time and treatments very important if you drop out early you're less likely to get the benefits of treatment then also you have the improvements in functioning and substance use academic performance problem behaviors and so forth so clearly you have benefits to families as well as the adolescents here you also have the outcomes of family interventions with family members without a substance use disorder so you can help the family even if the member doesn't get involved the member with the problem and John pointed out I think this is important I'm a licensed social worker and I'm also a trained family therapist and what I tell people is it you do not have to be a family therapist of social worker to help a family now that's not to say you do family therapy but there are a lot of interventions that can make a difference sometimes even a 15 minute phone call or face-to-face meeting when the family comes to a rehab or detox center can make a difference so the outcomes of some of the literature here show less conflict improved communication within the family and very important people feel better they're less angry they're less depressed the less anxious that emotional burden is we do significantly reduce welfare dependence as well so people are functioning better and then there's a literature on behavioral marital affair as well and this also shows when you get couples involved in treatment lower rates of substance use lower rates of relapses in fact on the one model adds relapse prevention to the marital therapy the behavioral marital therapy and that shows even better benefits you have lower levels of domestic violence you have reduction of HIV risk behaviors and as you all know that's been a major focus of the clinical trials Network how can reduce behaviors and increase the likelihood of HIV infection and then improvement in children and so we have lots of good therapies I think the problem is they're often not used very much now multi family groups are used a lot and there's more of a literature from the psychiatric side than the addiction side but multi family groups show positive outcomes as well and these are just some of them so you you have for example better employment outcomes reduce symptoms you have lower psychiatric relapse rates in fact within psychiatry there's the concept everyone doesn't agree with it it's called expressed emotion in families in which if the families are to a mess with the patient or if they're too hostile and negative and they're they're well over 30 studies mainly with schizophrenia and major mood disorders and what they find is that when families participate in therapy and they control these emotional reactions that there's a significant reduction in rehospitalization rates so that what that shows is the influence of the family on whether or not a patient has a recurrence of illness now they can still have a recurrence of illness but I think what that points out is that family members do affect the patient with the disorders and then as we said before the reduced family burden lower stress and you know again it's I've talked to so many families and I've seen people through this whole range of reactions from angry despondent oh my god I'm hopeless to a sense of serenity because they've accepted that they can only have so much an effect on their loved one and they have to focus on themselves and I think when family members start focusing on themselves that's an indication they're moving towards recovery because initially many family members who get involved in treatment do it for the loved one not for themselves and that's true also with mutual support programs that people go to Eleanor nar-anon where other family programs often they do it with the idea they want to help their loved one more than themselves though some of the interventions working with patient on the impact how have you affected your family as John said many individual models include family sessions encourage the patient to get the family involved in mutual support programs for addiction or mental illness such as a national lines in the mentally ill provide education support and referral I mean families need to understand the illness they need understand addiction is a disease they need to understand relapse John had talked about it being a chronic relapsing disease there's a difference between having a chronic relapsing disease and just what people considered bad behavior or unmotivated behavior but families aren't going to understand this if they don't get some education meeting with individual family members providing providing facilitating linking to family education groups and then you have family program that just as one example you have the matrix model I just pulled that out today they have a whole bag of three manuals and they have one for clinicians on the group and individual work mainly group work they have won manual for clients and recovery and then they have a manual for a family counseling as well you know where they they get have a curriculum to cover and they educate them and they get them involved there's opportunities to share as well and then the IMR is the illness management recovery model which is more for the chronic mental illness and their number space drove to US and other countries that show a lot of positive outcomes of that visa V the psychiatric symptoms and the functioning of the pace and the functioning of the family as well and then in some cases we might provide or we might facilitate therapy marital family therapy but there's again there's a difference between ongoing long-term therapy with some of the models proposed and just three family interventions and both are very important so the family member without the substance use disorder understanding accepting the problem supporting the recovery of the member with the addiction adjusting to the sobriety which is not always easy I mean I've had people in front of me tell their spouse they liked them better when they were drinking and then deal with the realities of lobsters and relapses you know these things happen with these chronic diseases family safety involvement in recovery reducing emotional burden and then helping other members get help if needed I've seen many spouses that were affected in ways that they had a clinical depression that they need to help for or you might find children in the same case they have problems with their behaviors they may be a stat or mom who has the addiction and this is I think this is so important to focus on self care but I think that's the most difficult things for family members to do because they're so giving and caring and loving to other people they often lose himself in the process so John is going to take over for here and then I learn with a couple comments on children so go ahead John Thank You Dennis I'm just going to speak briefly on some of the strategies to engage family members from a provider's perspective and one of the key starts to that is to look if you are a provider you work for a system of care is family ancient statement or involved in a family we actually changed our mission statement two years ago to include the recovery of family members because we believe that's an integral part of the recovery process our family is your do you have a family philosophy of care is it in your vision is it in your mission is it in your policies I we were in one of my residential programs years ago we were trying to boil down the common components and factors of people who graduated this six-month lengths of treatment at the time this residential program and what we found is one of the key components was involvement in family back then in this residential program family involvement was not an expectation like men dated or or standard or care but what was interesting is that eighty percent of the people who graduated had family involvement versus only twenty percent of the people without family involvement actually graduated so with such incredible numbers there in utilization of family and outcomes we changed our policies in our residential program to make it an expectation of treatment that family are significant and significant other involvement would be part of treatment is core part of treatment as core as individual and group involvement would be and we found that had a significant impact on increasing retention and positive outcomes for graduation by pulling the family member in as well so key to that though is it is right from the beginning of an intake or a phone screening in your agency sometimes there's a phone access people can come in or through their website or just walk in through an intake that when the person from the first phone call calls to ask for help we in our agency ask who will be participating in your recovery or who in your life is supportive of your recovery becomes a key important statement from the providers perspective that makes it a given that family members will be involved in the recovery process and if the person identifies somebody who will be coming in and being part of their recovery we asked them to please have them bring you to the screening and the intake there's even a practical liability exposure here where if you have somebody who's struggling and then the throes of addiction you don't want them behind the wheel coming to your appointment it's from a safety perspective it's great to have somebody drive them there but as soon as they come in we want them to orient them about the program we want the we have this expectation of them signing releases to include somebody who's going to participate in their program so it becomes a given and it doesn't come in like an opt-out option so we do this to have them understand their experiences it helps families engage in the process and we even work on doing outreach to connect to the families and an important piece is we don't take the clients word oftentimes they're not often the most credible self reporter on the fact that families can't come in and we reach out we think it's part of our professionalism to rehab their respect of calling the family members and trying to include them in the process and we reach out and try to call them directly to get permission to get them involved in the family process or find out what what are their concerns again it comes back to not needing a family therapist to make these phone calls but just a skilled clinician who understand the addiction and recovery who may even start to answer some of the questions on the phone such as what is this program about how long does it take what's the recovery process and start to answer questions as they come in of what do I do that may help support my loved ones recovery what have I done in the past that may have promoted their relapse and what am I willing to do differently that they need to be able to be empowered and sign up for so the key is being able to really pull them in and look through a humble lens and not knowing that family as well as that know they know what the strengths are in that family so you need to join with them enjoying quickly let them know that you need them that the therapist becomes part of the team and respect if a family says no for now and check back with them later to see if that has changed and again answer all their questions but to let the family member know we're in this together and that we are not the experts they are the experts of their family they know what makes their family tick again outreach if you needed try to stay away from labeling family is resistant to codependent and be patient flexible and accessible and look for incremental change and look for what the family would see is defining success as they would measure it so we try to have the clinicians provide education and support right from the beginning so the primary goal is to be able to support their loved ones recovery process and not inadvertently undermine it by not understanding what treatment is and what it isn't explore experiences concerns and questions really be able to listen to them and hear what their concerns are and deal with the challenges facing families the emotional burden that dennis spoke of their sense of they feeling like they're being in a blur and have them refrain enabling in a way that says that they just showed love the best way they knew how with the choices available to them at the time and have them learn how to redefine love in a manner that promotes their recovery and the recovery of their loved one facilitate individual assessments if needed and help parents focus on their children so again reducing the emotional chaos and burden of families is significant reducing the anxiety weary fear the anger resentment the guilt shame embarrassment the depression and grief there's more and more now in the field of resiliency that the more we can reduce that emotional burden and stress the more we can actually help individuals in that family become more resilient and hopeful improving communication becomes key and problem solving having clear communication of what recovery is and how they each person can be helpful to each other in their recovery process reduce negative interactions and communication try to increase positive strength-based communication and support solve current problems and increase family rituals the ground the family and positive interactions in a way that would give them a sense of grounding and hope in the future focus on self and family on significant other that is again the concept that the family members recovery is independent of their loved one that they their loved one can go out again and maybe 2015 may not be the year recovery for their loved one but it doesn't mean it can't be their year recovery to start a process of being able to make decisions that meet the needs of their conscience and be able to offer a sense of what's reasonable or what they can do what they can with regards to a sense of powerlessness in their loved one's life you oftentimes hear the expression tough love my concern is sometimes it comes across as too much tough and not enough love so a person has to be able to make decisions that they can reconcile that are reasonable that they can live with without knowing the outcome of how it may impact their loved one so again focus on the family member manage negative reactions deal with emotional burden give them the social support of other family members and that's what Alan on an errand on does so well and self-help support mutual support you know the pain doesn't cut as deep if the person realizes they're not alone and other family members have gone through similar struggles and this is also where they can learn resiliency as well and prepare for the challenges of recovery both for the patient and the family member yeah and i would add i'm thinking about the bridge to hope family support program that i tend sometimes and what's beautiful is if if you watch families who go to ellen on our non nami or meetings like this you will see people who are well grounded in recovery who we're doing a lot of these positive things and they may still be living with heartache and heartbreak because maybe their loved one still is using and being chaotic and so forth but you see their growth and then you see what they do to help the younger or the newer members as well and i think that's just a wonderful thing people helping each other in recovery because even though we're talking treatment here we're also promoting the idea of recovery then the last intervention is to focus on how do you get parents to help their children because children should not be forgotten because they are affected by these disorders as we had mentioned before from the research and from our clinical experience so they need an opportunity to share they need an opportunity to be protected from certain behaviors these are the high-risk behaviors violence and talking behaviors and then positive activities and family rituals are very important that John had mentioned and things that many of us take for granted you may not have regularly in families affected by more severe manifestations of addiction for example establish some normalcy as much as possible and probably it depends of the person with the disorder is living at home and if they're still actively using then you know that that's much more chaotic but family ritual is important on things that I mean if you think of your own families the things you do together really keep you well connected being interested in what's going on with the kid outside and the relationships that may help prevent them from getting into difficulty because sometimes kids express their frustration their anger by getting involved with other kids who are similar and get involved with kids that you know in trouble and they more likely get into trouble and also having child attend some of the sessions and i'm thinking i have a friend of my Robert Ackerman has written a lot on addiction the Family and Children and he wrote a book years ago called same house different homes where you could talk to two children in the same family and they have totally different experiences one's devastated by mom's addiction and the other is coping white well so you want to keep that in mind and the last point is very very very important is any time we figure out directly we've seen the child in a session we've heard from mother or father that this child has some kind of problems some kind of maybe suicidal may be very depressed trouble in school whatever getting help for the children any serious problem that may mean having to facilitate that and that is a tremendously helpful intervention because if you go back to what we said from the literature a large number of these kids are affected and will have serious problems as well so we um we appreciate Tracy pushing us along we wanted to cover this in about 50 minutes and then open this up for your comments or discussions about what are some of the potential research questions were issues to consider related to families Marcela sabur chio would you like to go ahead and adjust the truth yes thank you I am calling from Mexico and I was very happy to hear all the interesting approaches that were presented today and it's not a question of just a comment and I've been working with families in Mexico both in urban areas as well as indigenous areas where there are no treatment options and we have come with a brief intervention program that has has been tested for efficacy with very good results but the thing is that it is very encouraging to see that the families are being recognized not only as the the responsibles the main risk factor for the development of substance use disorders but also as the the most closed circle that suffers all the bad consequences of this consumption so it was very very interesting to see this presentation thank you thank you for your advice comments every Hamilton yep great job guys I didn't know anybody still remembered Robert Ackerman did one of the things that listening to and sometimes with adults we have a I don't want my mother involved I don't do not give up on that just because initially they didn't want their family involved but as they progressed sometimes they're more open to having families involved yeah and I think Neal t I think first of all it's always good to hear from Nancy Hamilton who's usually shy and doesn't share much I think patients fall to the lowest level of expectations so if you don't expect anything visa V the family you won't get anything and you may have to negotiate work with them but you can make a difference in terms of getting them to agree to bring families and it won't happen a hundred percent but it can happen a whole lot right sometimes you can go for it somebody that they trust is a little easier on them like your grandmother or their grandfather or some other member of their their extended family that they see as their ally yeah absolutely ally of confidante and some of the problem isn't in an actor addiction themselves inspecting the resiliency research the resilient kids adopt a functional healthy family that could be a neighbor and friends family and then even if there are no families involved to be able to be part of a group kind of the model of self-help reported that becomes a functional family for people the same thing for now I'm Erin on an Ellen on right I figure I think your families who never to say is your thing exactly right we have steves Ferran Borg who has a hand raised a glass iced tea hey garrison John thanks very much I find all of this fascinating and I wanted to know if there's any way that you can characterize generally the amount of time that a family member or all the family together spins in therapy in terms of number length of session number of sessions and how often do they do that with the substance abusing family member present in the counseling session that's a great question Steve and I think some of the minimum expectations of family involvement whether it's it's outpatient or residential is to bring the family into the screening and biopsychosocial process and assessment in the process and then determine whether or not that family would benefit from Family Education multiple multiple family therapy sessions if you haven't or individualized family therapy for that specific family but having an initial session in the beginning and then a check in session Midway for a progress report for how everyone's doing in treatment as a minimum and then again a very key piece is post discharge for discharge planning at the very minimum a third session to allow for a real responsible discharge plan to get the buy-ins of the family members of what they can support and not because if the family can't create a supportive recovery environment it does inform a treatment recommendation for sober housing or recovery housing or extended care yeah and Steve one of the answers to your question two is some of the models have discrete numbers of and it may be 12 it may be 20 20 for over six months or a year in the family therapy models with mental illness for example psychiatric illness they usually more severe manifestations like chronic schizophrenia or bipolar illness major depression would often stick with families for a long time for at least a year if not longer and they might include a combination of what's called family psycho wed workshops where you bring a few other for three hours four hours six hours and you give a lot of education have some supportive discussions and then you have them return for multi-family group sessions then you also have some individual sessions so they're all different models out there the matrix model if i recall had 12 group sessions each focused on a topic and then they had some dividual family sessions as well but because of the nature behaviorial health reimbursement system's you're seeing less and less sessions in fact you know it would be interesting to go to manage care companies and find out how much are they how many family sessions are they paying for and I hate to say it you'd probably see not that many the other thing I would urge you to think about to this is unrelated to treatment is the next 10 brochures you get in the mail for conferences related to mental illness addiction or both look to see how much focus is on the family and i bet you it's very very little and if you look at we appreciate you all being on today but you look at our tendons 40 people we've had in other topics we've had 125 150 people so you know this is a comment on where we're at but there's a question in the queue Richard our dos dias are there any funding resources that you are aware of to help nonprofit agencies implement a research project of evidence-based family intervention strategies John or Dennis well I can start and end Dennis probably have some resources as well but in our state we have our single state agency does small grants for implementation of evidence-based practices and again that does include evidence-based family models Samsa oftentimes has opportunities to keep an eye on some of their funding for integration of family into treatment and then NIDA has implementation science that probably Dennis can speak more of opportunities for research is to be able to study the impact of implementing family as an evidence-based practice in a community treatment provider yeah you might you could look at foundations to foundations may support a project related to what you're talking about the family and then someone had written about they used Laura had mentioned they use craft and I'm sorry there was a weight I lost this yeah wanted to know about therapist or programs are using alcohol behavioral couples counseling what you may check large is the veterans administration medical center they have a website where they have evidence-based practices that they expect to be used in different Veterans Hospital programs however having said that it doesn't mean they are using that but you probably could find some who are using that that approach but again what you what you are going to find is you have these good evidence-based interventions and they're not used a lot all right well that will have to be the last comment Thank You Dennis and John for facilitating this very important discussion if others are more interested in having additional discussions on this topic we can arrange for that in another session and then afterwards there will be a survey so please tell us how you felt about your experience on this session and I welcome everyone back next month when June tenth to discuss emotional brain training and substance use disorders and we have a industry expert here that will be our guest speaker for that session that will end our discussion today thank you thanks Tracy thanks John it will clearly bar you

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