Summary of the impact

Professor Alex Copello took a leading role in conducting research on the consequences of drug and alcohol addiction for the families of the substance users as well as the users themselves, leading to the Stress-Strain-Coping-Support (SSCS) model of understanding addictions and the impact of these problems on families. The model was used to develop and evaluate family treatment interventions. Compared with other psychosocial treatments for substance users, family treatment interventions have the key advantage of addressing the difficulties also experienced by families of substance users, in addition to the users themselves. This work has increased national and international recognition of the importance of families in treating substance addiction in policy, and has resulted in the needs of the family being recognised for the first time in the 10-year Drug Strategy for England in 2008. It has led to family-based interventions being recommended in national clinical guidance from NICE and from the National Treatment Agency for substance misusers. Copello and his team have been actively involved in training large numbers of clinical services and practitioners in the use of these therapeutic methods, and the methods are being adopted in many other countries.

Underpinning research

Research undertaken by Professor Copello (Honorary Professor of Addiction Research from 1996; Consultant Clinical Psychologist in Addictions at the Birmingham and Solihull Mental Health Foundation Trust; submitted as Cat C in 2008; research focussed at UoB) and colleagues (including Professor Orford, 1993-2007 at UoB and now Emeritus Professor) at the University of Birmingham during the late `90s led to the development of the stress-strain-coping-support (SSCS) model of inter-personal processes involving substance mis-users, through quantitative and qualitative research studies in three contrasting cultural groups (UK; Australia and Mexico). The main hypothesis was that the stress that emerges from the impact of living close to somebody with a substance misuse problem leads to stressful symptoms [1] and that these symptoms can be alleviated through brief psychological intervention strategies. The SSCS model provided a contrast to other existing theories that viewed difficulty among family members of people with addiction as a product of family dysfunction or deficiency. It filled an important gap in theory and practice, which had neglected impact on the family, and the possibility that the family might be an important target for intervention. The team's early research indicated that the needs of this group had been largely misunderstood and ignored, and that there was very little support available to families affected [2]. The research introduced the concept that having a close relative with a substance misuse problem constitutes a form of stressful life circumstance, often longstanding, which puts affected family members at risk of experiencing strain in the form of physical and/or psychological ill health.

Following the articulation of the model, two complementary interventions were developed, pilot tested and researched in randomised trials: the 5-Step Method [3] to help family members in their own right; and Social Behaviour and Network Therapy [4,5] where the psychosocial treatment for the substance user involves the participation of family members. Originally Social Behaviour and Network therapy was evaluated in the MRC-funded UK Alcohol Treatment Trial (UKATT), the largest trial of alcohol treatments conducted in the UK, which informs clinically effective and cost effective delivery of psychosocial interventions for alcohol problems. Professor Copello was one of the Principal Investigators in this trial. Social Behaviour and Network Therapy was shown to be as clinically effective and as cost effective as other evidence-based interventions for alcohol problems [5, 6], leading to significant reductions in addictive behaviour and improvements in mental health. Importantly, by providing a family-based approach to addiction intervention, this paved the way for the use of the complementary 5-Step-Method, which was shown to be effective in reducing significant stress experienced by family members of substance users.

The full programme of research focused on the 5-Step Method has recently been described and published in a special research supplement [1]. The 5-Step Method has now become a popular approach with organisations delivering services for families affected by substance misuse problems in the UK and other countries, with a number of these organisations having received training and delivering this approach.

Most recently the Department of Health has awarded Professor Copello a Health Technology Assessment grant to adapt and evaluate Social Behaviour and Network Therapy to work with young drug users and their families (see grant funding, below).

References to the research

SELECTED RESEARCH GRANT SUPPORT

• HTA 11/60/01- Adaptation and feasibility study of a family and social network intervention for young people who misuse alcohol and drugs. Health Technology Assessment, National Institute of Health Research (NIHR). £528,000. 2.5 years from 06/13.

• PB-PG-0610-22392 — A pilot study of a social network intervention for heroin users in opiate substitution treatment. NHS Research for Patient Benefit. £250,000 (with Dr Ed Day and colleagues). 3 years from 01/12.

• PB-PG-1010-23138 — A pilot study to assess the feasibility and impact of a motivational intervention on problem drug and alcohol use in adult mental health in-patient units. NHS Research for Patient Benefit. £234,269 (with Dr Hermine Graham and colleagues). 2 years from 06/12.

• Pilot study of Assertive Community Treatment in alcohol dependence. Medical Research Council. £397,378 (with Professor Colin Drummond and colleagues). 36 months from 06/08.

Details of the impact

Impact on Recognition and Health Policy

Copello's contribution to charting the scale and nature of how drug and alcohol addiction impact upon families of addicts, and in developing and evaluating psychological interventions, is exemplified in his co-authorship of a 2012 report to the UK Drugs Policy Commission [1]. Worldwide estimates of serious psychological impact on family members of people with alcohol and drug misuse problems suggest a minimum of 91 million individuals. In terms of illicit drug use in the UK for example, this report estimated that 1.5 million adult family members are affected by the drug misuse of someone in their family [1] and a further 3 million by alcohol misuse. The impact of drug misuse on the family costs the UK £1.8 billion per year with a much larger figure again if we add the impact of alcohol misuse [1].The stress-strain-coping-support (SSCS) model of addiction and the family and associated intervention methods have made an important impact in the area of addiction and more specifically in terms of the recognition of needs and the help and evidence-based support that is delivered to families affected by these highly prevalent problems.
As a direct result of these contributions to awareness and debate around addiction policy, needs of the families of people with drug problems were recognised for the first time in the ten-year Drug Strategy for England 2008-2018 and included in key objectives [2]. In addition guidelines for commissioning services for carers and families were produced by the National Treatment Agency [3] in a document entitled `Supporting and Involving Carers: A guide for commissioners and providers' (NTA, 2008) making reference to the work of Copello and other research collaborators as part of the recommendations.

Impact on Treatment Guidance

Copello has been invited to serve on two NICE guideline development groups examining evidence for psychological interventions for drug and alcohol problems (the latter was published during the REF period, in 2011) [4]. Both the 5-Step method and Social Behaviour and Network Therapy have been recommended for implementation in the guidelines produced. This has led to implementation of the 5-Step Method in family services and to a demand for training and of Social Behaviour and Network Therapy in more generic addiction treatment services. The family intervention strategies developed here and in an analogous earlier NICE development group for drug addition, have also contributed to the recent emphasis on `recovery' for drug treatment in England where the potential contribution of families to the recovery of people with drug problems is increasingly recognised and encouraged through practice. The National Treatment Agency for substance misuse recommends both the 5-Step Method and Social Behaviour and Network Therapy for implementation [3], and, as described below, these are increasingly being taken up by services.

Impact on practitioners and services

The NHS is just one provider of treatment and support for addiction, so it is significant that other key providers, including prominent addiction charities and organisations, have widely adopted the 5-Step method and Social Behaviour and Network Therapy. Copello and his team have been heavily involved in providing direct training, and in developing self-help materials that allow the methods to be used more widely. During the REF period, Copello has regularly provided training to large third sector organisations, including ADFAM [5], Addaction [6], SPODA [7], and Action on Addiction [8]. The training has focused on the 5-Step Method and its delivery including continuing supervision, and has helped therapists and support workers to deliver a structured approach when supporting family members. ADFAM [4] is the lead umbrella organisation in the UK supporting families affected by substance misuse, and providing advice and practical guidance and training to other groups and individuals working in the sector in England. The Family Support Network [9] is an analogous organisation working throughout the island of Ireland. Both have received regular training from the research team, and supply therapy sessions nationally.

International uptake.

The 5-Step Method work has led to developments in other countries, including most recently an international meeting that was organised in York (October 2012) funded by the Society for the Study of Addiction (SSA) and supported by the World Health Organisation. The meeting focused on the development and implementation of the 5-Step Method in countries including Australia, New Zealand, Nigeria, Uganda, Mexico, Brazil and South Africa. Work is currently ongoing in a number of these countries to develop, deliver and evaluate this approach and further funding has been obtained to develop an international alliance to support dissemination and implementation of the 5-Step Method in these various countries. The benefit of family-based approaches is recognised by trusts and charities, which are supporting the adoption of these methods [10].

Sources to corroborate the impact

[1] UK Drug Policy Commission (UKDPC). An independent body that provides objective analysis of the evidence concerning drug policy and practice. http://www.ukdpc.org.uk/publication/the-forgotten-carers/

[2] Archive document of the 2008-18 national drugs strategy.
webarchive.nationalarchives.gov.uk/20100419081707/http://drugs.homeoffice.gov.uk/publication-search/drug-strategy/drug-strategy-20082835.pdf?view=Binary

[3] National Treatment Agency for Substance Misuse (NTA). A National Health Service special health authority established to improve the availability, capacity and effectiveness of drug treatment in England. http://www.nta.nhs.uk/. www.nta.nhs.uk/uploads/chapter6.pdf

[4] NICE guidelines. CG115 — Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence.
http://publications.nice.org.uk/alcohol-use-disorders-diagnosis-assessment-and-management-of-harmful-drinking-and-alcohol-cg115/other-versions-of-this-guideline#full-guideline

[5] ADFAM. Families Drugs and Alcohol. Lead UK organisation supporting families affected by substance misuse and providing advice and practical guidance and training to other groups and individuals working in the sector. http://www.adfam.org.uk/. Training in 5-Step method
http://www.adfam.org.uk/news/105

[6] Addaction, on the delivery of the 5-Step Method.
http://www.addaction.org.uk/page.asp?section=106&search

[7] SPODA. One of the pioneer organisations developing services to address the wide range of issues facing families and carers affected by another person's substance use.
http://www.spoda.co.uk/

[8] Action on Addiction. http://www.actiononaddiction.org.uk/Family-Support/Professional-Development/Meet-the-trainers.aspx

[9] Family Support Network. An umbrella organisation that supports the development of family support groups and networks throughout the island of Ireland.
http://www.fsn.ie/news_events/index.html

[10] New Zealand alcohol addiction charity endorses the 5-step method.
http://www.kinatrust.org.nz/Subpages/SpecificPracticeModelsOfFamilyInclusivePractice.asp