by Linda Somerville
This paper will, firstly, give a brief summary of the effects on family members as a result of a loved one’s substance misuse. Secondly, policies in relation to this issue will be outlined in brief, both nationally and internationally. Thirdly, the 5-step method of helping family members affected by substance misuse will be discussed. Fourthly, family systems and co-dependency will be described and finally, the 5-step method will be contrasted with the family systems approach.
Effects on Families
There are a number of consequences associated with addiction within the family; these affect the physical and mental well-being of family members (Duggan, 2007; Peterson & McBride, 2002). The main consequence on family members to be highlighted is worry and stress, not only personally but also for the substance user (Copello et al., 2010a) which can, in turn, lead to chronic personal illness (orford et al., 2010a). Family members have to deal with stressful situations while dealing with a loved one’s addiction, such as financial difficulty, preoccupation with the drug user (Barnard, 2007), roles reversing within the family system, family rituals being neglected, intimidation and sometimes domestic violence (Copello et al., 2005; Kaufman, 1984).
Some earlier research on the effects of drug use perceived the family as being responsible for the drug use and Copello (1999: cited in Duggan, 2007) believes that this perception can still be evident in the work with families to date. Because of the social stigma attached to substance use many family members deal with a loved one’s addiction in isolation (White & Savage, 2008). It is estimated that for one drug user the consequences of addiction will have an impact on at least two family members (Copello et al., 1999: cited in Duggan, 2007; Peterson & McBride, 2002).
Policies in Relation to Substance Misuse
It is only within recent years that the negative consequence of addiction on families has been documented (Copello et al., 2005; Orford et al., 2007). Prior to this, the main focus was on the individual substance user as opposed to the family members. Services were mainly aimed at the individual substance user and usually only incorporated family members to encourage the substance user into treatment (Copello et al., 2010c; Lewis, 1989; White & Savage, 2008).
Ireland: In the Irish national Drugs Strategy 2009-2016 it mentions families 40 times throughout the document (Department of Community, Rural and Gaeltacht Affairs, 2009), whereas the Irish national Drug Strategy of 2001 cited families 10 times (Department of Tourism, Sport and Recreation, 2001). This strategy is an indication of how families are becoming more acknowledged in relation to drug use. In fact, the Minister of State with responsibility for the national Drugs Strategy at the time of publication, Mr. John Curran, stated that “I feel it is vital that we support families of problem drug users” (Department of Community, Rural and Gaeltacht Affairs, 2009: 3). It was also highlighted within this document that there are gaps for family support, with services mainly focusing on the individual drug user and this is also reflected by Peterson and McBride (2002). The national Drugs Strategy 2009-2016 recognises that “families should be seen as service users in their own right” (Department of Community, Rural and Gaeltacht Affairs, 2009: 51). The fact that families are cited in the national Drug Strategy shows that policies are starting to take into account that family members need support in coping with drug use. nevertheless there is also a view that policies are symbolic (Velleman, 2010).
Internationally: This move within the Irish policy system is, however, not reflected within European policy. Most of the European policies overlook the issues of families and drug use (Velleman, 2010) and where it does acknowledge this issue its main focus is on the impact of drug use on children of drug-using parents (Velleman, 2010). Furthermore United nations (Un) policy only refers to families in relation to prevention and, in addition, the World Health organisation (WHo) drug policy does not mention families, while their alcohol policy mentions families but only the harm caused to them, not the support or interventions that they need (Velleman, 2010).
The 5-Step Method
The 5-step method evolved from the stress-strain-coping-support model (Copello et al., 2010a; Peterson & McBride, 2002). Its aim is to develop interventions and services to help families in their own right cope with a loved one’s addiction. This model observes that affected family members are ordinary people living with a stressful situation which is not of their own making. The stress-strain-coping-support model has also been applied to health psychology for illness affecting a family member, such as cancer and dementia (Gallagher et al., 1994: cited in orford et al., 2005). Unlike other models it does not take the stance that family members are the cause of the loved one’s addiction. It recognises that family members need not be powerless; in fact, it believes that family members have the capacity to both improve their own health and also have an impact on the individual’s drug use (orford et al., 2010b). A particular aspect of the 5-step method is that it is not complex; furthermore it does not require extensive training. However, there is initial training required to deliver the model (Copello, 2010b).
Principles of the 5-Step Method
There are four key principles in the 5-step method outlined by Copello et al. (2010a). Firstly, the method is focused on the drug-using individual’s family members. Secondly, the method views family members as ordinary people living in highly stressful circumstances. Furthermore, one of the key themes is that with a level of knowledge and support, family members can cope and respond to the issue. Thirdly, the method is flexible and adaptable to a range of settings and circumstances. The steps can be combined and delivered in one single meeting. Fourthly, the model can be delivered by a range of professionals without needing lengthy training. Those using the 5-step method should have the skill of being non-judgemental, be curious about the family members’ circumstances and be prepared to explore their experience in-depth.
The 5-Steps Described
Stress: Because of the negative consequences associated with addiction, the 5-step method recognises that living with addiction is highly stressful, not only for the individual user but also the affected family members (Orford et al., 2010a). Since there is extreme compulsiveness attached to addiction, the affected family members are let down in different ways. The addiction causes tension and conflict and the family members are left unsure of how to cope with the behavioural changes in the individual drug user. This will in turn cause extreme stress on family members.
Strain: Strain is referred to by Orford et al. (2010a) as the “effects on family members’ health” (40). Strain is a direct consequence of stress. Because of the uncertainty of how to manage or cope, the stress can cause physical and psychological issues for family members. Family members have reported psychological symptoms such as anxiety, depression, panic attacks and suicidal thoughts, and physical symptoms such as headaches, hair loss, asthma, migraines and hypertension (Orford et al., 2010b).
Coping: Family members want to find the best way of dealing with the situation that they find themselves in (Orford et al., 2010b). They are faced with the task of trying to understand what is happening and looking at how best to respond to the situation. Orford et al. (2010b) describes three ways that affected family members can cope:
(1) ‘Putting up with it’; some family members are resigned to accepting things as they are. They try to resolve the situation by standing up to the individual but yet in the same light supporting them, yet many family members find this to be unsatisfactory.
(2) ‘Withdrawing and gaining independence’; family members can withdraw from the situation. This can be done by putting distance between themselves and the drug user, either emotionally or physically or both. Some family members, on having withdrawn from the individual, have gained some independence and control back into their lives (Orford et al., 2010b).
(3) ‘Standing up to it’; This could be described as family members no longer accepting the drug user’s negative behaviour and consequences associated with these behaviours – one example could be where family members no longer allow the drug user to control or manipulate them.
Families may find some ways of coping to be more useful than others and this depends on the family circumstances (Orford et al., 2010b).
Support: For family members, social support is seen as an important resource for coping and could be seen as a central theme (Orford et al., 2010a). Yet Orford et al. (2010b) highlight that there are many barriers in the way that affected family members receive support. Emotional support was mentioned as having the most effect, having someone to talk to and someone who listened was described as the best form of support (Orford et al., 2010b). The same authors highlight two kinds of support that stood out in their research, firstly, ‘coping support or feeling backed up’ – it was found that family members appreciated other people who supported their coping efforts. Secondly, ‘positive about the relative’ – it was felt that people who interacted positively with the drug user or felt that they deserved to be helped found that their supports were more productive.
The 5-step practice for Professionals
Step 1: ‘Getting to know the family member and the problem – exploring stresses and strains’. This step is described as the most important (Copello et al., 2010a). It is in this step that the professional aims to see how the problem is affecting the rest of the family. The professional needs to actively listen, display empathy and be able to manage emotions. It also needs to be remembered that this might have been a difficult step for the family member to take. The professional needs to equip themselves with awareness of the most common signs of stress and strain that affect family members and to explain that these problems are common and not unusual (Copello et al., 2010a).
Step 2: ‘Providing relevant information’. An indicator of stress on the family member is the lack of accurate knowledge about drug and alcohol use and their effects. Therefore, family members need to be equipped with useful information. It is important to get the balance correct, hence, too little information may cause distress to the family member or too much information may overwhelm the family member. The professional should also have relevant information on support services available for the family member (Copello et al., 2010a).
Step 3: ‘Exploring and discussing coping behaviours’. This step explores the ways in which family members have been responding to the situation. It should be kept in mind that each family is unique and that no particular way of coping is universally better than another (Copello et al., 2010a). The first task is to discuss the ways in which the family members are coping. The second is to evaluate the advantages and disadvantages of these ways. The third is to explore alternative ways of coping and the fourth is to find out the advantages and disadvantages of these new alternatives (Copello et al., 2010a).
Step 4: ‘Exploring and enhancing social supports’. This step is concerned with exploring the social supports available to the family member. The overall aim of this step is to explore the supports available to the family member to help build a strong support system (Copello et al., 2010a).
Step 5: ‘Ending and exploring additional needs and further sources of help’. It may have become evident throughout the sessions that the family member may need additional support in other areas, such as help for the individual drug user or help for other family members. They may also need guidance in other areas such as marital advice or financial management.
The Family Systems Approach
The family systems approach was most prevalent in the 1970s and 1980s (Orford et al., 2005). Its view was that the individual substance user was not solely the problem but that in fact the overall family system was (Janzen, 1978; Kaufman, 1984). This approach has been described as a ‘family pathology model’ (Orford et al., 2005). Prior to the 1960s the main focus of research was on the wives of alcoholics. Researchers viewed the wives as having problems themselves; hence they were suffering themselves from forms of psychopathology. Wives were viewed as having chosen the alcoholic to meet their own dependency needs (White & Savage, 2005). It was in the 1960s that parents, particularly mothers, then became the focus of criticism over their child’s drug use. The overall family system was labelled as ‘dysfunctional’, with a long list of family deficiencies reported by Jurich et al. (1985) playing a contributory factor to drug use. The family were observed as ‘enabling’ the drug-using individual and it was assumed the best way to deal with them was by displaying ‘tough love’ tactics, presuming that this would force the individual to hit ‘rock bottom’ therefore initiating recovery (White & Savage, 2005).
The Co-dependency Approach
The co-dependency movement emerged in the 1980s (White & Savage, 2005). Theorists (see Anderson, 1994) maintained that co-dependency qualified as a personality disorder and should be included in the Diagnostic and Statistical Manual of Mental Disorders (at that time in its Third Edition). The co-dependency theory claims that the spouse becomes addicted to the relationship or the negative consequences associated with addiction (Peterson & McBride, 2002). Furthermore, it was assumed that if the co-dependent individual was not treated then they will enter into another addictive relationship. When co- dependency first transpired it was mainly aimed at women. Wives of alcoholics were labelled as co-dependent because they were viewed as ‘loving too much’, therefore they were seen as being overinvolved, putting others’ needs before their own and depending on others for approval (Anderson, 1994). However, co-dependency moved from women specifically to being applied to men and also families; it has also been reported that individuals who are co-dependent come from dysfunctional families (Stafford, 2001). Co-dependency self-help groups were established and it was estimated in 1990 that there were some 1,600 registered groups worldwide (White & Savage, 2005).
There has been criticism over the concept of co-dependency (Orford et al., 2005). Professionals in favour of co-dependency believed it to be present from early childhood and, furthermore, they believe that the individual purposively enters into addictive relationships (Anderson, 1994). Yet other theorists believe that there is no such ‘disease’ as co- dependency, that, in fact, family members are merely responding to the stressful situation that they find themselves in (Orford et al., 2010a). In addition, Orford et al. (2005) highlights that no two definitions of co-dependency are the same, that many characteristics have been observed, and for that reason co-dependency could easily be applied to anybody. It was in 1990–1995 that the co-dependency movement received the most criticism (White & Savage, 2005). There was a decline in treatment services for co-dependent individuals and many family programmes were terminated. Insurance companies would no longer provide payments for co-dependency as it was viewed that nearly everyone could suffer from this ‘disease’ (White & Savage, 2005). nevertheless there are still self help groups operating known as Co-Dependency Anonymous (CODA), who rely on the 12-step traditions, and in Dublin there are four groups a week (Co-Dependency Anonymous Ireland, 2012).
Contrasting the 5-Steps Method with the Family Systems Approach
Orford et al. (2010a) best describes the way in which family members were previously treated as a “sorry tale” (1). However the authors do go on to highlight that as a result of this it would explain why family members have been marginalised. The 5-step method recognises that family members are living within stressful circumstances and the model works towards how best to support them in this. In contrast, proponents of the 5-step method believe that the family systems’ approach viewed the family as being the cause of the addiction and saw the family as a nuisance or a threat to the individual’s recovery (White & Savage, 2005). The 5-step method considers that family members are not powerless in maintaining their own health or indeed in assisting the drug using individual. However, the family systems approach is seen to believe that family members are powerless in helping the drug using individual (Orford et al., 2010a). Orford et al. (2010a) are highly critical of the family systems approach, arguing that this approach considers the family members to be pathological, dysfunctional and to have deficiencies within the overall family system and for this reason they found that family members needed individual therapy to ‘fix them’. on the other hand, the 5-step method does not view the family as a whole, as does the family systems approach, nor does it see the family members in a pathological way. Additionally, it believes that the family member has the capacity to cope. Furthermore, the 5-step method is structured around focusing on family members’ general health and is not specifically addiction-orientated, unlike the family systems approach which believes that the family should be specifically educated around addiction (Orford et al., 2010a). In addition, the delivery for the 5-step method is not complex, in fact many professionals can deliver it (Copello et al., 2010b). Orford et al. (2010a) states that
the weight of all those unsympathetic past theories about affected family members forms the background against which the model was developed (38).
It is clear that family members have historically been stigmatised as a result of a loved one’s addiction. It is only within the last few years that it has been recognised that family members suffer extreme stress and strain at the hands of a loved one’s addiction. Yet policies and services are still slow to respond to these needs of family members.
The 5-step method is a unique way of working with family members. It draws on the family members’ coping skills and is delivered in a non- judgemental form and does not engage in blaming or stigmatising. Unlike other models it does not take the stance that family members are powerless in assisting the individual drug user. nor does it perceive that family members are suffering from a form of a personality disorder (co-dependency).
With the fact that at least two family members are affected by a loved one’s addiction it would be hoped that this model could be delivered across all drug services. It is also hoped that services dealing with individual drug users will equip their professional workers with training in the 5-step method, so family members can also avail of supports in their own right and that services do not just focus on the individual drug user.
For further information on the 5-Step Method you can visit the Family Support network’s website on www.fsn.ie or contact them on 01-8980148/01-5589628.
Linda Somerville is a Community Drugs Worker in a methadone clinic in the Dublin area, she also volunteers in an emergency homeless shelter. She has recently completed an MSc in Drug and Alcohol Policy with Trinity College Dublin.
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