The stress-coping-health model
An important principle of this model is that relatives are at risk of physical and psychological health problems which result from their daily exposure to stress arising from the alcohol-drug problem within the family. Relatives actively respond to these stresses through actions that are termed coping. Coping in itself, as well as social support, can influence the strain experienced by the relative and in addition influence the course and severity of the drug-alcohol problem. The stress-coping health model emphasizes the interactions between relatives and their alcohol-drug using family members. These interactions can have different results for both parties and some relatives may inadvertently use strategies that may compound the alcohol-drug problem. Relatives, however, are not seen as a cause of the addiction problem. Causes of addiction are multiple and when someone develops such a problem both family members and alcohol/drug users become victims of stress.
As can be seen from the ordering of the steps, the emphasis was initially placed upon information gathering and exploration of stress and concerns. As the intervention progressed, the focus moved towards coping and social support. The manual was written in such a way that the amount of input could be varied according to the client’s needs. The maximum number of sessions was five but even a single session could be used. In addition to the manual, a range of information leaflets was included with the package.
Step I - Getting To Know The Relative And The Problem – Identifying Stresses And Strains
This work relates to the first encounter with a relative. Emphasis was placed on the style of interaction between the primary care professional and the relative, given the need to create the necessary conditions for exploration and engagement. The interview style involved active listening, the development of empathy and the ability to deal with emotions. An important issue was the promotion of realistic optimism for the relatives.
An important aspect of the work within this step was the identification of stresses and the way in which stress was manifested for the particular relative. Orlord et al. (1 998a), based on qualitative analyses of semi-structured interviews, suggested certain core aspects of the experience of relatives which appear to be universal irrespective of culture, socio-economic status, gender of the relative or type of substance used. These include the drinker or drug user being not pleasant to live with, the relative being concerned over the user’s health or performance, the financial irregularities and the impact on the whole family and the home. In addition, relatives are concerned about other members of the community becoming involved in the problem, secrecy, the alcohol/drug user disappearing from the home for prolonged periods and the fact that the social life for the relative and the whole family is affected. A separate study of young adults living in families where there was an alcohol problem yielded similar findings. While growing up in these families, children were found to experience parental rows, the parent being moody, critical, foolish and embarrassing, special occasions being spoilt, the family having a restricted social life and both parent- to-parent and to a lesser extent parent-to-child violence (Velleman & Orford, 1990; 1999).
One of the ways in which family strain manifests itself is in the form of health problems. Research has consistently supported the fact that relatives of those with alcohol and drug problems show levels of physical and psychological symptoms which are much higher than control groups of families who are not living with this problem (Meyers et al., 1996; Orford et al, 2000) and that as a result they make more use of medical services (Roberts & Brent, 1982; Svenson et al., 1995). The evidence that the levels of symptoms are reduced following either separation or improvement of the alcohol/drug problem lends further support to the notion that living with addiction to alcohol and drugs may be a significant cause of these symptoms (Bailey, 1967; Moos et al., 1990).
Again, further evidence of such psychological and physical health problems comes from the studies of children and adolescents living within families with alcohol problems. Reviews of research have concluded that the evidence is consistent in showing that young people living at home where a parent has a drinking problem are at risk for psychological problems of various kinds including emotional problems, conduct problems and school learning difficulties (Velleman & Orford, 1999).
Having become familiar with the most common stresses and strains through training, the main task for the primary care professional within this step was to elicit from the relative information about his/her experience and where relevant to relate this experience to what is known from research. An important issue within this step was communicating to the relative the idea that these problems are common and that he/she is not unusual. The focus of this work is on the relative’s experience and stress as opposed to the details of the drinking/drug taking. The guidelines for conducting this step are summarized in Table 2.
Step 2 – Providing Relevant Information
An important contributor to stress is the lack of accurate knowledge about alcohol and drugs, their effects and issues of dependence. As part of an attempt to reduce this level of stress, information was provided at this stage. The aim of this strategy was to correct misunderstandings and misconceptions and to give relevant information in an objective manner. Leaflets were used in cases where this was perceived as helpful but professionals were trained to carefully select relevant information and not to use information to substitute face-to-face discussion. In addition, details of local and national agencies were made available to professionals so that if necessary they could guide relatives towards other sources of help.
Step 3 - Counseling About Coping
This constituted a central aspect of the intervention. Primary care professionals, however, were advised not to engage in a detailed discussion of coping early on in the contact with the relative as early mention of coping is sometimes perceived by the relative as an indication that he/she is not coping adequately (Howells, 1996). The material used for this section was based on a typology of coping developed from research (Orford et al., 1992, 1998b). Coping was used to refer to any actions, feelings, positions that relatives adopt in response to the alcohol/drug problem. Research has confirmed the existence of three distinct ways of coping or coping positions used by relatives, namely engaged, tolerant and withdrawal (Orlord et al., I 998b). Table 3 illustrates these three ways of coping with excessive alcohol/drug use in the family together with examples, common thoughts and emotions and possible advantages and disadvantages associated with each type.
In practice, these ways of coping are experienced as dilemmas by relatives. This experience results from the fact that both positive and negative outcomes can result from the same ways of coping. This generates a state of ambivalence and uncertainty in the relative as to which way to follow. The aim of this step was to discuss advantages and disadvantages of the relative’s current ways of coping, to raise awareness of alternative ways of coping, and the possible advantages and disadvantages of these. The overall goal was to empower relatives by enabling them to see that there are alternative ways of responding to their circumstances.
One important issue that professionals were trained to consider, however, is that tolerant coping in general, and self-sacrificing forms in particular (i.e. coping which includes actions which clearly remove the consequences of the drink or drug use at the expense of the relative’s or the family’s well-being. Examples include clearing up mess the user had made after he/she had been drinking/using drugs; giving the user money even when the relative thought it would be spent on drink or drugs; making excuses and covering up for the user; the relative taking blame her/himself) tend to be associated with worse physical and psychological symptoms (Orford et al., 2000), yet can fairly quickly be modified through discussion with a consequent reduction in the experience of stress for the relative (Copello et al., 2000; Howells, 1996).
Step 4 - Exploring And Enhancing Social Support
The level of social support available for relatives can have a significant impact on their ability to cope and their experienced stress. People’s social resources vary, however, and hence it was necessary to understand what sources of either positive or unhelpful support were present for each particular relative. Research has shown that commonly, relatives feel unsupported in their coping efforts, particularly from other family members (Orford et al., 1 998c). A number of problems have been reported to interfere with relatives’ receiving support including: lack of communication within the family; disagreements about how to cope; and the fact that some people who could potentially be supportive, distance themselves from the problem.
Informed by these research findings and following a careful review of the current social environment for each relative, the professionals were instructed to discuss with the relative ways in which he/she could attempt to maximize positive support while at the same time attempting to neutralize or reduce unhelpful actions (some professionals used a diagrammatic representation of the relative’s social support network in order to conduct this step). Where appropriate, the discussion focused on how to encourage more open communication within the family.
Step 5 - Ending And Discussing The Need For Further Help
Brief interventions can be effective and in most cases in our work we have found no need to refer the relative for further specialist input. The latter situation does occasionally arise, however, and therefore professionals were trained to respond effectively. Professionals were prepared to anticipate four possible scenarios: • Further help needed for the relative in his or her own right • Further help needed for the alcohol/drug user in his/her own right • Further help needed for the family as a whole • Further help needed for other family members (i.e. not the relative that received the intervention)
The important issue at this stage was for the professionals to be familiar with what was available locally and/or to consult local addiction services for advice. Professionals were also encouraged to familiarize themselves with the referral procedures of the practice within which they worked.
Responding when the user comes forward requesting help
Recent evidence suggests that a high percentage of alcohol/drug users enter treatment as a result of an initial contact with a relative or concerned significant other person (Barber & Crisp, 1995; Meyers et al., 1996). As mentioned, professionals were trained to be familiar with the referral procedures of their practice and to try to take advantage of this opportunity when it arose.
Professionals were trained to consider key issues when responding to this situation:
1. The concerned relative with whom the work was conducted initially needed to remain at the centre of the intervention. Often, and for understandable reasons, the relative feels relief from the fact that the problem drug/alcohol user comes for help and she/he may be tempted to drop out from the contact with the professional in order to make room for the problem user. The fact that the problem user has approached the service, however, may constitute the first step in a process of engagement and treatment and the specific needs of the problem alcohol/drug-using relative may need to be met elsewhere. Furthermore, the situation may not change for some time and hence it is important that the door remains open for the relative With whom the work was initially conducted.
2. The fact that the problem drug/alcohol user has come for help should be seen as a very positive event. This ought to be communicated to both family members in a clear and supportive fashion.
3. As far as possible, open communication between the relative and the problem alcohol/drug user needs to be encouraged.
4. Professionals need to be aware of sources of help and referral procedures and if necessary refer on for further help promptly.
- Copello, Alex et al; “Methods for reducing alcohol and drug related family harm in non-specialist settings”; Journal of Mental Health; Jun2000, Vol. 9 Issue 3; p329-343
Reflection Exercise #8
The preceding section contained information
about methods for reducing harm in the families of addicts. Write
three case study examples regarding how you might use the content of this section
in your practice.
Online Continuing Education QUESTION
According to Copello, what are the five steps for reducing harm in the families of addicts? Record the letter of the correct answer